Transitions in care are vulnerable periods. As patients are transferred between settings of care (such as from hospital back to the community), communication between healthcare providers is vital for care continuity.[1] A significant number of preventable adverse events may be related to ineffective communication between care providers.[1, 2, 3] The advent of specialized care, such as the introduction of hospitalists in acute care settings, has created an environment in which a patient's most responsible physician can often change multiple times as they move through the healthcare system.[4] Although there are many benefits to this type of concentrated care, the increase in care transitions may result in breakdowns in communication that may then be linked to risks in patient safety and suboptimal patient outcomes.[5, 6, 7, 8]

Improved continuity of care has been demonstrated to enhance patient safety during care transitions.[7] Efforts to develop continuity of care interventions are largely focused on care‐provider continuity, improved facilitation of communication, care planning, and increasing involvement of primary care physicians during follow‐up to hospitalizations and specialist visits.[9, 10] Such continuity of care efforts may provide a moderate benefit, but there remains room for improvement.[10, 11]

One dimension of continuity of care that has received limited attention is the potential impact of primary care physicians hospital visits to their hospitalized patients in a supportive‐care role.[12] In these situations, the primary care physician is neither the most responsible physician nor are they involved directly in their patient's hospital care. However, visiting their patient implies that they are aware of the hospitalization, thereby facilitating the potential for communication between care providers. Primary care physicians can also provide valuable contextual and relevant information as well as be involved in the discharge process. To identify the extent to which primary care physicians visit hospitalized patients and to measure the potential impact of primary care physician supportive visits on future outcomes, we used population‐level data to determine the frequency of supportive‐care visits by primary care physicians to hospitalized patients and to identify the association between these visits, patient outcomes, and health services utilization.

METHODS

RESULTS

Overview

There were 11,316 primary care physicians identified as practicing in Ontario during the study period, of which 3236 had a history of conducting regular in‐hospital visits to 2 or more patients. The final patient cohort consisted of 164,059 hospitalized patients; 19,614 patients received a visit from their primary care physician, whereas 144,445 did not (Figure 1).

Figure 1

The hospitalized patients who received a visit from their primary care physician were significantly different than the patients who did not receive an in‐hospital visit (Table 1). Notably, patients who received a visit by their primary care physician had longer lengths of hospital stay (9.7 days vs 6.8 days, P<0.001). As well, a greater proportion had a high 30‐day readmission risk (LACE score10: 39.4% vs 29.9%, P<0.001) (Table 1).[21]

Table 1.Patient Characteristics for the Cohort

Variablea	With PCP Visit (N=19,614)	Without PCP Visit (N=144,445)
NOTE: Abbreviations: ED, emergency department; PCP, primary care physician; SD, standard deviation. a All results are statistically significantly different (P<0.0001). b Low income is defined as individual income below $16,018 (CND) or couples income below $24,175 (CND). c LACE score is a validated measure predicting readmission risk and accounts for length of stay, acute admission, comorbid disease burden, and number of ED visits in previous 6 months. The probability of readmissions range from 2% for a score of 0 to 43.7% for a LACE score of 19; LACE score of 10 corresponds to a probability of readmission of 12.2%.[20]
Age, meanSD	68.3716.85	65.7318.54
Sex, no. of males	9,393 (47.9%)	67,030 (46.4%)
Low income	3,937 (20.1%)	30,157 (20.9%)
Individuals living in rural regions, no.	1,951 (9.9%)	25,731 (17.8%)
PCP visits in previous 6 months, meanSD	4.764.47	4.174.28
Length of stay, d, meanSD	9.7217.40	6.7913.17
Acute emergent visits, no.	19,138 (97.6%)	136,374 (94.4%)
Charlson score, meanSD	1.061.60	0.921.49
ED visits in previous 6 months, meanSD	0.951.48	1.091.98
LACE score, meanSDc	9.022.88	8.103.02
High risk for readmission (LACE score10), no. (%)c	7,721 (39.4%)	43,126 (29.9%)

Patients who received an in‐hospital visit by their primary care physician were significantly different from those who did not (Table 2). They were older (68.4 years vs 65.7 years), and had a higher risk of readmission (LACE score of 9 vs 8). As well, proportionally fewer patients who received a visit were from rural regions than in the comparator group (9.9% of patients visited were from rural regions vs 17.8% of patients who did not receive a visit) (Table 2).

Table 2.Results for Primary Outcome of Emergency Department Visit, Hospital Readmission, or Death at 30 and 90 Days PostHospital Discharge and Secondary Outcome of PCP Office Visits and Home‐Care Services

Variable	Patients Who Received an In‐hospital Visit (N=19,614)	Patients Who Did Not Receive an In‐hospital Visit (N=144,445)	P Value
NOTE: Abbreviations: ED, emergency department; PCP, primary care physician; SD, standard deviation. a Composite endpoint=readmission, ED visit, or death. b Composite endpoint=community PCP visit or home‐care service.
Primary outcome of emergency department visit, hospital readmission, or death
30 days postdischarge, no. (%)
Readmission	1,742 (8.9%)	11,212 (7.8%)	<0.001
ED visit	2,039 (10.4%)	16,823 (11.6%)	<0.001
Death	727 (3.7%)	4,688 (3.2%)	<0.001
Composite endpointa	4,227 (21.6%)	30,848 (21.4%)	0.533
90 days postdischarge
Readmission	2,791 (14.2%)	18,257 (12.6%)	<0.001
ED visit	3,652 (18.6%)	29,590 (20.5%)	<0.001
Death	1,507 (7.7%)	9,821 (6.8%)	<0.001
Composite endpointa	7,125 (36.3%)	52,245 (36.2%)	0.668
Secondary outcome of PCP office visits and home‐care services
30 days postdischarge
Community PCP visits, meanSD	3.85.1	3.14.6	<0.001
PCP visit, no. (%)	15,732 (80.2%)	108,266 (75%)	<0.001
Home‐care services, no. (%)	6,197 (31.6%)	38,745 (26.8%)	<0.001
Composite endpoint, no. (%)b	16,851 (85.9%)	117, 290 (81.2%)	<0.001
90 days postdischarge
Community PCP visits, meanSD	8.210.1	6.99.3	<0.001
PCP visit, no. (%)	18,112 (92.3%)	128, 806 (89.2%)	<0.001
Home‐care services, no. (%)	7,256 (37.0%)	45,675 (31.6%)	<0.001
Composite endpoint, no. (%)b	18, 504 (94.3%)	132, 448 (91.7%)	<0.001

DISCUSSION

Our population‐based study of primary care physicians is among the first to examine outcomes of patients whose primary care physicians have a history of providing supportive visits to hospitalized patients. After controlling for risk differences in patients at hospital discharge, we found that a primary care physician visit to a patient in the hospital was associated with a lower adjusted risk for the composite outcome of death, emergent hospital readmission, or emergency department visit at 30 and 90 days postdischarge compared to hospitalized patients who did not receive a visit by their primary care physician. We found this to be driven by patients having a lower risk of emergency department visits and death, whereas there was a similar risk of hospital readmission. We also found that visited patients were more likely to access home‐care services and have more primary care physician visits in the community following discharge.

The unadjusted model differs substantially from the adjusted model. On the surface this is an apparent paradox where the unadjusted results suggest an association with potential harm or no difference with a supportive visit. Conversely, the adjusted model suggests a reduction in harms. The differences between the unadjusted and adjusted model is driven by changes in the point estimates for readmission and death rates at both 30 and 90 day postdischarge. Prior to adjustment, it appears as if a primary care physician visit is associated with a significant increase of death; however, upon adjustment, it is associated with a significant reduction in death. Interestingly, this is a different effect than that observed with the secondary analysis, where the adjusted analyses demonstrate a more modest (but still positive) effect of supportive‐care visits. This observed change is likely due to differences in the patient groups. We can speculate that this may be an observed phenomenon of primary care physicians opting to visit their sicker patients, as perhaps it should be; however, further research is required to fully understand the real drivers of a supportive visit.

Our results are consistent with an earlier study that identified that a minority number of primary care physicians visit their hospitalized patients.[24] As well, findings from a randomized controlled trial of 364 patients over 60 years old identified a limited impact of primary care physician visits on patient outcomes but noted enhanced access to community health services.[12] Our work highlights the potential impact of primary care physician visits, which could, in theory, be leveraged and be an important role that primary care physicians can play in planning postdischarge care and improving the quality of care following hospitalization.

Our research study did not examine the impact of in‐hospital primary care physician visits on patient satisfaction directly. However, it has been demonstrated that patients have a strong desire for their primary care physician to be involved in their hospital care and their preference is for direct contact, with face‐to‐face visits compared to telephone or other communication.[25] This choice is important because dissatisfaction with services is associated with a loss of patient confidence in care quality and decreased adherence.[26] Also, primary care physicians acknowledge that information exchange is lacking when their patients are discharged, and that improving this aspect of a patient's care transition is important.[20] Research into discharge summaries as a tool to fill the communication gap has noted some success, yet there remains uncertainty regarding the type of information that should be included in a discharge summary, the time frame in which primary care physicians actually receive the summaries, and the accuracy of the information provided.[20, 27]

Our use of population‐based administrative data sources make the findings of our research generalizable to other similarly designed healthcare systems where a primary care physician may visit their hospitalized patients in a supportive‐care role. We were interested in a complex patientphysician interaction with a number of potential confounding factors, and our use of a composite measure represents the broad outcomes from this contact. Our cohort methodology was designed to isolate the exposure of interest while maximizing uniformity between the 2 study groups on other characteristics. Additionally a number of potential confounding factors were considered in an effort to isolate the effect of the primary care physician in‐hospital visit such as age, comorbid disease, and risk of hospital readmission.[12] The findings of our work support that of earlier research, but on a broader and more generalizable scale.[12]

There were notable differences between the intervention and control patient populations in the proportion of patients from rural regions who receive a supportive visit. This may be due to systemic differences between rural and nonrural regions with regard to access to care and ease of visit by primary care physicians. Alternatively, observed differences may be due to limitations of our study design in that some rural environments rely on primary care physicians to be involved in hospital care for the region. As such, they may actually be visiting their patients in a manner that was not captured as a supportive‐care visit. This is an important area that should be pursued in the future.

We acknowledge there are limits to our research findings. First, the nature of administrative data introduces challenges to causal inferences. As such, we are careful to describe associations and not draw causative links as there may be additional variables influencing outcomes including the patientphysician relationship, the location of the hospital relative to the physician practice and/or home, the time of the primary care physician visit, primary care physician hospital privileges for supportive‐care visits, and the number of other patients the primary care physician had in the same hospital at the same time. A second limitation is the use of the selected outcomes, which may not be direct measures of care quality.[28] However, the selected outcomes have been shown to be good quality measures in other work relevant to health policy.[8, 20, 21, 29] Third, the use of a composite outcome may over‐ or underestimate an exposure's impact.[19] Our composite outcome might have been dominated by some of its components. These observations may reflect the reality of primary care physicians visiting their sicker patients, or may be an attribute of the relatively short length of follow‐up of the study design. Fourth, we cannot determine whether there were additional interventions in place that assisted the continuity of care for primary care physician visits.[20, 27] However, this research included a broad range of hospitals throughout a large province where there were no system‐level quality interventions applied during this time. Fifth, our readmission rate may appear lower than other studies. However, our analysis is population based and not limited in focus to seniors.[30] As well, our posthospitalization death rates are similar to others, and the readmission rates are comparable to other Canadian studies.[31] Sixth, patients at higher risk for adverse outcomes may be identified as requiring more communication with their primary care physicians and we may not have fully captured this risk in our adjustment models, thereby underestimating the effect of exposure.[27] Further, primary care physicians may be involved in major medical decisions such as transitions to palliative care. A supportive‐care visit that facilitated these transitions and its ensuing outcomes may not have been included in our analysis. Seventh, our inherent assumption is that more care, such as posthospital primary care visits and home visits, denotes better care. This may not always be the case.[32] Eighth, physicians may find it difficult to visit their patient in the hospital, even when asked.[12] Finally, our findings are contingent on a system that supports primary care physicians being aware of their patients who become hospitalized. This is not only incumbent on any individual (eg, hospitalist) but a system where all providers work cohesively and seamlessly. On balance, however, these limitations do not overshadow our study's findings and conclusions.

Visits by primary care physicians to hospitalized patients are a longstanding tradition. The practice likely varies according to regional, patient, and individual physician characteristics.[16, 17, 18, 25] However, reimbursement codes for these services are present in a number of international healthcare systems' physician fee schedules with fairly modest remuneration amounts. The fairly nominal fee of less than $20 CND for a supportive‐care visit is similar to other systems and does not constitute a strong financial incentive to encourage this practice. The fee likely compensates the primary care physician for some of their time but comes with an opportunity cost to other aspects of their practice. Thus, results may differ in other environments or if the fee were higher, thereby incenting more primary care physicians to conduct visits. Indeed, the entire program for supportive hospital visits cost approximately $2.5 million CND per year for the 13 million people in the province of Ontario. Future work in this area could address the overall value and cost‐effectiveness of any potential fee changes. Still, it highlights the generalizability of our findings to other health systems and the ease in assessing the effect of the practice.

Overall, our findings underscore the importance and relevance for the practice of supportive‐care visits in its association with patient outcomes and health services utilization, which may prove to be an important key factor to improve quality healthcare. Our results suggest that an in‐hospital visit by a primary care physician may improve patient outcomes and increase subsequent support in the community. An in‐hospital supportive visit may be an additional method by which primary care physicians, and healthcare systems as a whole, strive to achieve the best care for patients.

Transitions in care are vulnerable periods. As patients are transferred between settings of care (such as from hospital back to the community), communication between healthcare providers is vital for care continuity.[1] A significant number of preventable adverse events may be related to ineffective communication between care providers.[1, 2, 3] The advent of specialized care, such as the introduction of hospitalists in acute care settings, has created an environment in which a patient's most responsible physician can often change multiple times as they move through the healthcare system.[4] Although there are many benefits to this type of concentrated care, the increase in care transitions may result in breakdowns in communication that may then be linked to risks in patient safety and suboptimal patient outcomes.[5, 6, 7, 8]

Improved continuity of care has been demonstrated to enhance patient safety during care transitions.[7] Efforts to develop continuity of care interventions are largely focused on care‐provider continuity, improved facilitation of communication, care planning, and increasing involvement of primary care physicians during follow‐up to hospitalizations and specialist visits.[9, 10] Such continuity of care efforts may provide a moderate benefit, but there remains room for improvement.[10, 11]

One dimension of continuity of care that has received limited attention is the potential impact of primary care physicians hospital visits to their hospitalized patients in a supportive‐care role.[12] In these situations, the primary care physician is neither the most responsible physician nor are they involved directly in their patient's hospital care. However, visiting their patient implies that they are aware of the hospitalization, thereby facilitating the potential for communication between care providers. Primary care physicians can also provide valuable contextual and relevant information as well as be involved in the discharge process. To identify the extent to which primary care physicians visit hospitalized patients and to measure the potential impact of primary care physician supportive visits on future outcomes, we used population‐level data to determine the frequency of supportive‐care visits by primary care physicians to hospitalized patients and to identify the association between these visits, patient outcomes, and health services utilization.

METHODS

RESULTS

Overview

There were 11,316 primary care physicians identified as practicing in Ontario during the study period, of which 3236 had a history of conducting regular in‐hospital visits to 2 or more patients. The final patient cohort consisted of 164,059 hospitalized patients; 19,614 patients received a visit from their primary care physician, whereas 144,445 did not (Figure 1).

Figure 1

The hospitalized patients who received a visit from their primary care physician were significantly different than the patients who did not receive an in‐hospital visit (Table 1). Notably, patients who received a visit by their primary care physician had longer lengths of hospital stay (9.7 days vs 6.8 days, P<0.001). As well, a greater proportion had a high 30‐day readmission risk (LACE score10: 39.4% vs 29.9%, P<0.001) (Table 1).[21]

Table 1.Patient Characteristics for the Cohort

Variablea	With PCP Visit (N=19,614)	Without PCP Visit (N=144,445)
NOTE: Abbreviations: ED, emergency department; PCP, primary care physician; SD, standard deviation. a All results are statistically significantly different (P<0.0001). b Low income is defined as individual income below $16,018 (CND) or couples income below $24,175 (CND). c LACE score is a validated measure predicting readmission risk and accounts for length of stay, acute admission, comorbid disease burden, and number of ED visits in previous 6 months. The probability of readmissions range from 2% for a score of 0 to 43.7% for a LACE score of 19; LACE score of 10 corresponds to a probability of readmission of 12.2%.[20]
Age, meanSD	68.3716.85	65.7318.54
Sex, no. of males	9,393 (47.9%)	67,030 (46.4%)
Low income	3,937 (20.1%)	30,157 (20.9%)
Individuals living in rural regions, no.	1,951 (9.9%)	25,731 (17.8%)
PCP visits in previous 6 months, meanSD	4.764.47	4.174.28
Length of stay, d, meanSD	9.7217.40	6.7913.17
Acute emergent visits, no.	19,138 (97.6%)	136,374 (94.4%)
Charlson score, meanSD	1.061.60	0.921.49
ED visits in previous 6 months, meanSD	0.951.48	1.091.98
LACE score, meanSDc	9.022.88	8.103.02
High risk for readmission (LACE score10), no. (%)c	7,721 (39.4%)	43,126 (29.9%)

Patients who received an in‐hospital visit by their primary care physician were significantly different from those who did not (Table 2). They were older (68.4 years vs 65.7 years), and had a higher risk of readmission (LACE score of 9 vs 8). As well, proportionally fewer patients who received a visit were from rural regions than in the comparator group (9.9% of patients visited were from rural regions vs 17.8% of patients who did not receive a visit) (Table 2).

Table 2.Results for Primary Outcome of Emergency Department Visit, Hospital Readmission, or Death at 30 and 90 Days PostHospital Discharge and Secondary Outcome of PCP Office Visits and Home‐Care Services

Variable	Patients Who Received an In‐hospital Visit (N=19,614)	Patients Who Did Not Receive an In‐hospital Visit (N=144,445)	P Value
NOTE: Abbreviations: ED, emergency department; PCP, primary care physician; SD, standard deviation. a Composite endpoint=readmission, ED visit, or death. b Composite endpoint=community PCP visit or home‐care service.
Primary outcome of emergency department visit, hospital readmission, or death
30 days postdischarge, no. (%)
Readmission	1,742 (8.9%)	11,212 (7.8%)	<0.001
ED visit	2,039 (10.4%)	16,823 (11.6%)	<0.001
Death	727 (3.7%)	4,688 (3.2%)	<0.001
Composite endpointa	4,227 (21.6%)	30,848 (21.4%)	0.533
90 days postdischarge
Readmission	2,791 (14.2%)	18,257 (12.6%)	<0.001
ED visit	3,652 (18.6%)	29,590 (20.5%)	<0.001
Death	1,507 (7.7%)	9,821 (6.8%)	<0.001
Composite endpointa	7,125 (36.3%)	52,245 (36.2%)	0.668
Secondary outcome of PCP office visits and home‐care services
30 days postdischarge
Community PCP visits, meanSD	3.85.1	3.14.6	<0.001
PCP visit, no. (%)	15,732 (80.2%)	108,266 (75%)	<0.001
Home‐care services, no. (%)	6,197 (31.6%)	38,745 (26.8%)	<0.001
Composite endpoint, no. (%)b	16,851 (85.9%)	117, 290 (81.2%)	<0.001
90 days postdischarge
Community PCP visits, meanSD	8.210.1	6.99.3	<0.001
PCP visit, no. (%)	18,112 (92.3%)	128, 806 (89.2%)	<0.001
Home‐care services, no. (%)	7,256 (37.0%)	45,675 (31.6%)	<0.001
Composite endpoint, no. (%)b	18, 504 (94.3%)	132, 448 (91.7%)	<0.001

DISCUSSION

Our population‐based study of primary care physicians is among the first to examine outcomes of patients whose primary care physicians have a history of providing supportive visits to hospitalized patients. After controlling for risk differences in patients at hospital discharge, we found that a primary care physician visit to a patient in the hospital was associated with a lower adjusted risk for the composite outcome of death, emergent hospital readmission, or emergency department visit at 30 and 90 days postdischarge compared to hospitalized patients who did not receive a visit by their primary care physician. We found this to be driven by patients having a lower risk of emergency department visits and death, whereas there was a similar risk of hospital readmission. We also found that visited patients were more likely to access home‐care services and have more primary care physician visits in the community following discharge.

The unadjusted model differs substantially from the adjusted model. On the surface this is an apparent paradox where the unadjusted results suggest an association with potential harm or no difference with a supportive visit. Conversely, the adjusted model suggests a reduction in harms. The differences between the unadjusted and adjusted model is driven by changes in the point estimates for readmission and death rates at both 30 and 90 day postdischarge. Prior to adjustment, it appears as if a primary care physician visit is associated with a significant increase of death; however, upon adjustment, it is associated with a significant reduction in death. Interestingly, this is a different effect than that observed with the secondary analysis, where the adjusted analyses demonstrate a more modest (but still positive) effect of supportive‐care visits. This observed change is likely due to differences in the patient groups. We can speculate that this may be an observed phenomenon of primary care physicians opting to visit their sicker patients, as perhaps it should be; however, further research is required to fully understand the real drivers of a supportive visit.

Our results are consistent with an earlier study that identified that a minority number of primary care physicians visit their hospitalized patients.[24] As well, findings from a randomized controlled trial of 364 patients over 60 years old identified a limited impact of primary care physician visits on patient outcomes but noted enhanced access to community health services.[12] Our work highlights the potential impact of primary care physician visits, which could, in theory, be leveraged and be an important role that primary care physicians can play in planning postdischarge care and improving the quality of care following hospitalization.

Our research study did not examine the impact of in‐hospital primary care physician visits on patient satisfaction directly. However, it has been demonstrated that patients have a strong desire for their primary care physician to be involved in their hospital care and their preference is for direct contact, with face‐to‐face visits compared to telephone or other communication.[25] This choice is important because dissatisfaction with services is associated with a loss of patient confidence in care quality and decreased adherence.[26] Also, primary care physicians acknowledge that information exchange is lacking when their patients are discharged, and that improving this aspect of a patient's care transition is important.[20] Research into discharge summaries as a tool to fill the communication gap has noted some success, yet there remains uncertainty regarding the type of information that should be included in a discharge summary, the time frame in which primary care physicians actually receive the summaries, and the accuracy of the information provided.[20, 27]

Our use of population‐based administrative data sources make the findings of our research generalizable to other similarly designed healthcare systems where a primary care physician may visit their hospitalized patients in a supportive‐care role. We were interested in a complex patientphysician interaction with a number of potential confounding factors, and our use of a composite measure represents the broad outcomes from this contact. Our cohort methodology was designed to isolate the exposure of interest while maximizing uniformity between the 2 study groups on other characteristics. Additionally a number of potential confounding factors were considered in an effort to isolate the effect of the primary care physician in‐hospital visit such as age, comorbid disease, and risk of hospital readmission.[12] The findings of our work support that of earlier research, but on a broader and more generalizable scale.[12]

There were notable differences between the intervention and control patient populations in the proportion of patients from rural regions who receive a supportive visit. This may be due to systemic differences between rural and nonrural regions with regard to access to care and ease of visit by primary care physicians. Alternatively, observed differences may be due to limitations of our study design in that some rural environments rely on primary care physicians to be involved in hospital care for the region. As such, they may actually be visiting their patients in a manner that was not captured as a supportive‐care visit. This is an important area that should be pursued in the future.

We acknowledge there are limits to our research findings. First, the nature of administrative data introduces challenges to causal inferences. As such, we are careful to describe associations and not draw causative links as there may be additional variables influencing outcomes including the patientphysician relationship, the location of the hospital relative to the physician practice and/or home, the time of the primary care physician visit, primary care physician hospital privileges for supportive‐care visits, and the number of other patients the primary care physician had in the same hospital at the same time. A second limitation is the use of the selected outcomes, which may not be direct measures of care quality.[28] However, the selected outcomes have been shown to be good quality measures in other work relevant to health policy.[8, 20, 21, 29] Third, the use of a composite outcome may over‐ or underestimate an exposure's impact.[19] Our composite outcome might have been dominated by some of its components. These observations may reflect the reality of primary care physicians visiting their sicker patients, or may be an attribute of the relatively short length of follow‐up of the study design. Fourth, we cannot determine whether there were additional interventions in place that assisted the continuity of care for primary care physician visits.[20, 27] However, this research included a broad range of hospitals throughout a large province where there were no system‐level quality interventions applied during this time. Fifth, our readmission rate may appear lower than other studies. However, our analysis is population based and not limited in focus to seniors.[30] As well, our posthospitalization death rates are similar to others, and the readmission rates are comparable to other Canadian studies.[31] Sixth, patients at higher risk for adverse outcomes may be identified as requiring more communication with their primary care physicians and we may not have fully captured this risk in our adjustment models, thereby underestimating the effect of exposure.[27] Further, primary care physicians may be involved in major medical decisions such as transitions to palliative care. A supportive‐care visit that facilitated these transitions and its ensuing outcomes may not have been included in our analysis. Seventh, our inherent assumption is that more care, such as posthospital primary care visits and home visits, denotes better care. This may not always be the case.[32] Eighth, physicians may find it difficult to visit their patient in the hospital, even when asked.[12] Finally, our findings are contingent on a system that supports primary care physicians being aware of their patients who become hospitalized. This is not only incumbent on any individual (eg, hospitalist) but a system where all providers work cohesively and seamlessly. On balance, however, these limitations do not overshadow our study's findings and conclusions.

Visits by primary care physicians to hospitalized patients are a longstanding tradition. The practice likely varies according to regional, patient, and individual physician characteristics.[16, 17, 18, 25] However, reimbursement codes for these services are present in a number of international healthcare systems' physician fee schedules with fairly modest remuneration amounts. The fairly nominal fee of less than $20 CND for a supportive‐care visit is similar to other systems and does not constitute a strong financial incentive to encourage this practice. The fee likely compensates the primary care physician for some of their time but comes with an opportunity cost to other aspects of their practice. Thus, results may differ in other environments or if the fee were higher, thereby incenting more primary care physicians to conduct visits. Indeed, the entire program for supportive hospital visits cost approximately $2.5 million CND per year for the 13 million people in the province of Ontario. Future work in this area could address the overall value and cost‐effectiveness of any potential fee changes. Still, it highlights the generalizability of our findings to other health systems and the ease in assessing the effect of the practice.

Overall, our findings underscore the importance and relevance for the practice of supportive‐care visits in its association with patient outcomes and health services utilization, which may prove to be an important key factor to improve quality healthcare. Our results suggest that an in‐hospital visit by a primary care physician may improve patient outcomes and increase subsequent support in the community. An in‐hospital supportive visit may be an additional method by which primary care physicians, and healthcare systems as a whole, strive to achieve the best care for patients.

Transitions in care are vulnerable periods. As patients are transferred between settings of care (such as from hospital back to the community), communication between healthcare providers is vital for care continuity.[1] A significant number of preventable adverse events may be related to ineffective communication between care providers.[1, 2, 3] The advent of specialized care, such as the introduction of hospitalists in acute care settings, has created an environment in which a patient's most responsible physician can often change multiple times as they move through the healthcare system.[4] Although there are many benefits to this type of concentrated care, the increase in care transitions may result in breakdowns in communication that may then be linked to risks in patient safety and suboptimal patient outcomes.[5, 6, 7, 8]

Improved continuity of care has been demonstrated to enhance patient safety during care transitions.[7] Efforts to develop continuity of care interventions are largely focused on care‐provider continuity, improved facilitation of communication, care planning, and increasing involvement of primary care physicians during follow‐up to hospitalizations and specialist visits.[9, 10] Such continuity of care efforts may provide a moderate benefit, but there remains room for improvement.[10, 11]

One dimension of continuity of care that has received limited attention is the potential impact of primary care physicians hospital visits to their hospitalized patients in a supportive‐care role.[12] In these situations, the primary care physician is neither the most responsible physician nor are they involved directly in their patient's hospital care. However, visiting their patient implies that they are aware of the hospitalization, thereby facilitating the potential for communication between care providers. Primary care physicians can also provide valuable contextual and relevant information as well as be involved in the discharge process. To identify the extent to which primary care physicians visit hospitalized patients and to measure the potential impact of primary care physician supportive visits on future outcomes, we used population‐level data to determine the frequency of supportive‐care visits by primary care physicians to hospitalized patients and to identify the association between these visits, patient outcomes, and health services utilization.

METHODS

RESULTS

Overview

There were 11,316 primary care physicians identified as practicing in Ontario during the study period, of which 3236 had a history of conducting regular in‐hospital visits to 2 or more patients. The final patient cohort consisted of 164,059 hospitalized patients; 19,614 patients received a visit from their primary care physician, whereas 144,445 did not (Figure 1).

Figure 1

The hospitalized patients who received a visit from their primary care physician were significantly different than the patients who did not receive an in‐hospital visit (Table 1). Notably, patients who received a visit by their primary care physician had longer lengths of hospital stay (9.7 days vs 6.8 days, P<0.001). As well, a greater proportion had a high 30‐day readmission risk (LACE score10: 39.4% vs 29.9%, P<0.001) (Table 1).[21]

Table 1.Patient Characteristics for the Cohort

Variablea	With PCP Visit (N=19,614)	Without PCP Visit (N=144,445)
NOTE: Abbreviations: ED, emergency department; PCP, primary care physician; SD, standard deviation. a All results are statistically significantly different (P<0.0001). b Low income is defined as individual income below $16,018 (CND) or couples income below $24,175 (CND). c LACE score is a validated measure predicting readmission risk and accounts for length of stay, acute admission, comorbid disease burden, and number of ED visits in previous 6 months. The probability of readmissions range from 2% for a score of 0 to 43.7% for a LACE score of 19; LACE score of 10 corresponds to a probability of readmission of 12.2%.[20]
Age, meanSD	68.3716.85	65.7318.54
Sex, no. of males	9,393 (47.9%)	67,030 (46.4%)
Low income	3,937 (20.1%)	30,157 (20.9%)
Individuals living in rural regions, no.	1,951 (9.9%)	25,731 (17.8%)
PCP visits in previous 6 months, meanSD	4.764.47	4.174.28
Length of stay, d, meanSD	9.7217.40	6.7913.17
Acute emergent visits, no.	19,138 (97.6%)	136,374 (94.4%)
Charlson score, meanSD	1.061.60	0.921.49
ED visits in previous 6 months, meanSD	0.951.48	1.091.98
LACE score, meanSDc	9.022.88	8.103.02
High risk for readmission (LACE score10), no. (%)c	7,721 (39.4%)	43,126 (29.9%)

Patients who received an in‐hospital visit by their primary care physician were significantly different from those who did not (Table 2). They were older (68.4 years vs 65.7 years), and had a higher risk of readmission (LACE score of 9 vs 8). As well, proportionally fewer patients who received a visit were from rural regions than in the comparator group (9.9% of patients visited were from rural regions vs 17.8% of patients who did not receive a visit) (Table 2).

Table 2.Results for Primary Outcome of Emergency Department Visit, Hospital Readmission, or Death at 30 and 90 Days PostHospital Discharge and Secondary Outcome of PCP Office Visits and Home‐Care Services

Variable	Patients Who Received an In‐hospital Visit (N=19,614)	Patients Who Did Not Receive an In‐hospital Visit (N=144,445)	P Value
NOTE: Abbreviations: ED, emergency department; PCP, primary care physician; SD, standard deviation. a Composite endpoint=readmission, ED visit, or death. b Composite endpoint=community PCP visit or home‐care service.
Primary outcome of emergency department visit, hospital readmission, or death
30 days postdischarge, no. (%)
Readmission	1,742 (8.9%)	11,212 (7.8%)	<0.001
ED visit	2,039 (10.4%)	16,823 (11.6%)	<0.001
Death	727 (3.7%)	4,688 (3.2%)	<0.001
Composite endpointa	4,227 (21.6%)	30,848 (21.4%)	0.533
90 days postdischarge
Readmission	2,791 (14.2%)	18,257 (12.6%)	<0.001
ED visit	3,652 (18.6%)	29,590 (20.5%)	<0.001
Death	1,507 (7.7%)	9,821 (6.8%)	<0.001
Composite endpointa	7,125 (36.3%)	52,245 (36.2%)	0.668
Secondary outcome of PCP office visits and home‐care services
30 days postdischarge
Community PCP visits, meanSD	3.85.1	3.14.6	<0.001
PCP visit, no. (%)	15,732 (80.2%)	108,266 (75%)	<0.001
Home‐care services, no. (%)	6,197 (31.6%)	38,745 (26.8%)	<0.001
Composite endpoint, no. (%)b	16,851 (85.9%)	117, 290 (81.2%)	<0.001
90 days postdischarge
Community PCP visits, meanSD	8.210.1	6.99.3	<0.001
PCP visit, no. (%)	18,112 (92.3%)	128, 806 (89.2%)	<0.001
Home‐care services, no. (%)	7,256 (37.0%)	45,675 (31.6%)	<0.001
Composite endpoint, no. (%)b	18, 504 (94.3%)	132, 448 (91.7%)	<0.001

DISCUSSION

Our population‐based study of primary care physicians is among the first to examine outcomes of patients whose primary care physicians have a history of providing supportive visits to hospitalized patients. After controlling for risk differences in patients at hospital discharge, we found that a primary care physician visit to a patient in the hospital was associated with a lower adjusted risk for the composite outcome of death, emergent hospital readmission, or emergency department visit at 30 and 90 days postdischarge compared to hospitalized patients who did not receive a visit by their primary care physician. We found this to be driven by patients having a lower risk of emergency department visits and death, whereas there was a similar risk of hospital readmission. We also found that visited patients were more likely to access home‐care services and have more primary care physician visits in the community following discharge.

The unadjusted model differs substantially from the adjusted model. On the surface this is an apparent paradox where the unadjusted results suggest an association with potential harm or no difference with a supportive visit. Conversely, the adjusted model suggests a reduction in harms. The differences between the unadjusted and adjusted model is driven by changes in the point estimates for readmission and death rates at both 30 and 90 day postdischarge. Prior to adjustment, it appears as if a primary care physician visit is associated with a significant increase of death; however, upon adjustment, it is associated with a significant reduction in death. Interestingly, this is a different effect than that observed with the secondary analysis, where the adjusted analyses demonstrate a more modest (but still positive) effect of supportive‐care visits. This observed change is likely due to differences in the patient groups. We can speculate that this may be an observed phenomenon of primary care physicians opting to visit their sicker patients, as perhaps it should be; however, further research is required to fully understand the real drivers of a supportive visit.

Our results are consistent with an earlier study that identified that a minority number of primary care physicians visit their hospitalized patients.[24] As well, findings from a randomized controlled trial of 364 patients over 60 years old identified a limited impact of primary care physician visits on patient outcomes but noted enhanced access to community health services.[12] Our work highlights the potential impact of primary care physician visits, which could, in theory, be leveraged and be an important role that primary care physicians can play in planning postdischarge care and improving the quality of care following hospitalization.

Our research study did not examine the impact of in‐hospital primary care physician visits on patient satisfaction directly. However, it has been demonstrated that patients have a strong desire for their primary care physician to be involved in their hospital care and their preference is for direct contact, with face‐to‐face visits compared to telephone or other communication.[25] This choice is important because dissatisfaction with services is associated with a loss of patient confidence in care quality and decreased adherence.[26] Also, primary care physicians acknowledge that information exchange is lacking when their patients are discharged, and that improving this aspect of a patient's care transition is important.[20] Research into discharge summaries as a tool to fill the communication gap has noted some success, yet there remains uncertainty regarding the type of information that should be included in a discharge summary, the time frame in which primary care physicians actually receive the summaries, and the accuracy of the information provided.[20, 27]

Our use of population‐based administrative data sources make the findings of our research generalizable to other similarly designed healthcare systems where a primary care physician may visit their hospitalized patients in a supportive‐care role. We were interested in a complex patientphysician interaction with a number of potential confounding factors, and our use of a composite measure represents the broad outcomes from this contact. Our cohort methodology was designed to isolate the exposure of interest while maximizing uniformity between the 2 study groups on other characteristics. Additionally a number of potential confounding factors were considered in an effort to isolate the effect of the primary care physician in‐hospital visit such as age, comorbid disease, and risk of hospital readmission.[12] The findings of our work support that of earlier research, but on a broader and more generalizable scale.[12]

There were notable differences between the intervention and control patient populations in the proportion of patients from rural regions who receive a supportive visit. This may be due to systemic differences between rural and nonrural regions with regard to access to care and ease of visit by primary care physicians. Alternatively, observed differences may be due to limitations of our study design in that some rural environments rely on primary care physicians to be involved in hospital care for the region. As such, they may actually be visiting their patients in a manner that was not captured as a supportive‐care visit. This is an important area that should be pursued in the future.

We acknowledge there are limits to our research findings. First, the nature of administrative data introduces challenges to causal inferences. As such, we are careful to describe associations and not draw causative links as there may be additional variables influencing outcomes including the patientphysician relationship, the location of the hospital relative to the physician practice and/or home, the time of the primary care physician visit, primary care physician hospital privileges for supportive‐care visits, and the number of other patients the primary care physician had in the same hospital at the same time. A second limitation is the use of the selected outcomes, which may not be direct measures of care quality.[28] However, the selected outcomes have been shown to be good quality measures in other work relevant to health policy.[8, 20, 21, 29] Third, the use of a composite outcome may over‐ or underestimate an exposure's impact.[19] Our composite outcome might have been dominated by some of its components. These observations may reflect the reality of primary care physicians visiting their sicker patients, or may be an attribute of the relatively short length of follow‐up of the study design. Fourth, we cannot determine whether there were additional interventions in place that assisted the continuity of care for primary care physician visits.[20, 27] However, this research included a broad range of hospitals throughout a large province where there were no system‐level quality interventions applied during this time. Fifth, our readmission rate may appear lower than other studies. However, our analysis is population based and not limited in focus to seniors.[30] As well, our posthospitalization death rates are similar to others, and the readmission rates are comparable to other Canadian studies.[31] Sixth, patients at higher risk for adverse outcomes may be identified as requiring more communication with their primary care physicians and we may not have fully captured this risk in our adjustment models, thereby underestimating the effect of exposure.[27] Further, primary care physicians may be involved in major medical decisions such as transitions to palliative care. A supportive‐care visit that facilitated these transitions and its ensuing outcomes may not have been included in our analysis. Seventh, our inherent assumption is that more care, such as posthospital primary care visits and home visits, denotes better care. This may not always be the case.[32] Eighth, physicians may find it difficult to visit their patient in the hospital, even when asked.[12] Finally, our findings are contingent on a system that supports primary care physicians being aware of their patients who become hospitalized. This is not only incumbent on any individual (eg, hospitalist) but a system where all providers work cohesively and seamlessly. On balance, however, these limitations do not overshadow our study's findings and conclusions.

Visits by primary care physicians to hospitalized patients are a longstanding tradition. The practice likely varies according to regional, patient, and individual physician characteristics.[16, 17, 18, 25] However, reimbursement codes for these services are present in a number of international healthcare systems' physician fee schedules with fairly modest remuneration amounts. The fairly nominal fee of less than $20 CND for a supportive‐care visit is similar to other systems and does not constitute a strong financial incentive to encourage this practice. The fee likely compensates the primary care physician for some of their time but comes with an opportunity cost to other aspects of their practice. Thus, results may differ in other environments or if the fee were higher, thereby incenting more primary care physicians to conduct visits. Indeed, the entire program for supportive hospital visits cost approximately $2.5 million CND per year for the 13 million people in the province of Ontario. Future work in this area could address the overall value and cost‐effectiveness of any potential fee changes. Still, it highlights the generalizability of our findings to other health systems and the ease in assessing the effect of the practice.

Overall, our findings underscore the importance and relevance for the practice of supportive‐care visits in its association with patient outcomes and health services utilization, which may prove to be an important key factor to improve quality healthcare. Our results suggest that an in‐hospital visit by a primary care physician may improve patient outcomes and increase subsequent support in the community. An in‐hospital supportive visit may be an additional method by which primary care physicians, and healthcare systems as a whole, strive to achieve the best care for patients.

In July 2003, as a fresh intern, I was introduced to care transitions and our tool for information transfer at hospital dischargethe fax machine. After writing our discharge order and discharge prescriptions, the team would compose the discharge summary and transmit the document via fax. I asked my resident where these faxes were going, because they were all sent to the same number in the hospital. Humorously, he did not know. Summaries were completed within days, or sometimes weeks, of discharge and faxed to a mysterious destination for filing and presumably for dissemination to outside providers. The message was clear to me that discharge summaries were not very useful or important, and they were definitely not seen as a critical part of the care‐transition process.

This attitude toward the discharge summary is not surprising. Historically, when physicians cared for their patients prior to, during, and after hospitalization, the goal of the discharge summary was to document patients' care for hospital records. It was not critical as a communication tool unless a patient was being transferred to another healthcare facility and a new care team. However, that all changed with decreasing hospital length of stay, the contemporaneous rise in postacute care discharges, the rise of the hospitalist care model, and the resulting transition of care from hospitalist to outpatient physician. Clear, rapid completion and communication of discharge summaries became essential for safe transitions in care.

The lack of focus on the discharge summary as a communication tool is reflected in regulations and standards of accreditation bodies. In 1986, the Medicare Condition of Participation required that inpatient records be completed within 30 days of discharge. Despite all of the changes in healthcare, the 30‐day requirement for discharge summary completion has persisted, often as a medical staff requirement. Similarly, The Joint Commission requires that discharge summaries include 6 components (reason for hospitalization, findings, treatment provided, discharge condition, instructions, and physician signature) but does not provide a timeframe. As a result of this lack of emphasis on timely completion of discharge summaries, studies have shown that although summaries usually include core elements, they are not completed in a timely fashion. Consequently, most postdischarge visits occur without the benefit of a discharge summary.[1] The most complex patients, who ideally are seen within a few days of discharge, are the least likely to have received the discharge summary at the first postdischarge visit.

Although it seems intuitively obvious that more timely communication of discharge summaries should lead to better outcomes, especially lower readmission rates, few studies have examined this issue, and the findings have not been consistent.[2, 3, 4, 5] Is it possible that physicians and other members of the healthcare team often communicate with each other through telephone calls and text messaging, especially about the sickest patients? If so, timely discharge summaries could have a small marginal effect on outcomes. Therefore, the study in this issue of the Journal of Hospital Medicine by Hoyer and colleagues is a welcome addition to the literature.[6] They found that discharge summary completion 3 or more days after discharge was associated with an adjusted odds ratio of 1.09, and the odds ratio increased with every additional 3‐day delay in completion.

It is possible that the analysis by Hoyer et al. underestimated the benefit of timely discharge summaries. To achieve full benefit, the discharge summary must be completed, accurately delivered, read by the receiving provider, and used at the first follow‐up visit. Their claims‐based analysis did not contains these latter elements, which would bias their results toward the null hypothesis. Future studies should examine how receipt of a summary, as opposed to transmission, is associated with postdischarge outcomes.

In subgroup analyses, no associations between discharge summary timeliness and readmissions were found for patients cared for on the gynecology‐obstetrics and surgical sciences services. Although caution is always needed when interpreting subgroup analyses, it is possible that the lack of association is attributable to the relatively acute conditions of many patients on these services, the relative provider continuity that persists in surgical disciplines, or whether these disciplines use other means of communication more frequently (eg, postdischarge phone calls among providers), mitigating the impact of the written discharge summary. Additional studies are needed to examine these issues. In addition, studies should examine how community or social factors might attenuate the benefit of timely communication, and explore the effect of discharge summaries on outcomes for patients admitted to an observation level of care, which is increasingly common and for which discharge summaries are less likely to be required.

The findings of the study by Hoyer et al. support proposed federal legislationthe Improving Medicare Post‐Acute Care Transformation Act of 2014. The proposed rule for discharge planning would change the Medicare Conditions of Participation to require transmission of discharge information, including the discharge summary, within 48 hours of discharge (https://federalregister.gov/a/2015‐27840A).[7] If enacted, this rule could substantially improve the timely availability of discharge information following care transition.

Fortunately, the work of preparing and transmitting the discharge summary is already part of the physician workflow, albeit often delayed. This traditional means of communication could even remain unchanged in form, if the order of the workflow could be altered in terms of timeliness, and no additional work would be created. With the hospitalization fresher in memory at the time of discharge, work might even be reduced. This efficiency presents a reasonable and immediately actionable appeal to providers.

The challenge to providers and systems remains to refine the quality and efficiency of communication and to move health communication into the 21st century. Tremendous potential exists for interactive communication among providers at discharge, which will not only build the quality of information delivered, but possibly also the qualitative experience of communication, building relationships in our increasingly complex and fragmented delivery networks. This may be a disappointment to the manufacturers of fax machines, but it will be a welcome improvement for caregivers and patients.

In July 2003, as a fresh intern, I was introduced to care transitions and our tool for information transfer at hospital dischargethe fax machine. After writing our discharge order and discharge prescriptions, the team would compose the discharge summary and transmit the document via fax. I asked my resident where these faxes were going, because they were all sent to the same number in the hospital. Humorously, he did not know. Summaries were completed within days, or sometimes weeks, of discharge and faxed to a mysterious destination for filing and presumably for dissemination to outside providers. The message was clear to me that discharge summaries were not very useful or important, and they were definitely not seen as a critical part of the care‐transition process.

This attitude toward the discharge summary is not surprising. Historically, when physicians cared for their patients prior to, during, and after hospitalization, the goal of the discharge summary was to document patients' care for hospital records. It was not critical as a communication tool unless a patient was being transferred to another healthcare facility and a new care team. However, that all changed with decreasing hospital length of stay, the contemporaneous rise in postacute care discharges, the rise of the hospitalist care model, and the resulting transition of care from hospitalist to outpatient physician. Clear, rapid completion and communication of discharge summaries became essential for safe transitions in care.

The lack of focus on the discharge summary as a communication tool is reflected in regulations and standards of accreditation bodies. In 1986, the Medicare Condition of Participation required that inpatient records be completed within 30 days of discharge. Despite all of the changes in healthcare, the 30‐day requirement for discharge summary completion has persisted, often as a medical staff requirement. Similarly, The Joint Commission requires that discharge summaries include 6 components (reason for hospitalization, findings, treatment provided, discharge condition, instructions, and physician signature) but does not provide a timeframe. As a result of this lack of emphasis on timely completion of discharge summaries, studies have shown that although summaries usually include core elements, they are not completed in a timely fashion. Consequently, most postdischarge visits occur without the benefit of a discharge summary.[1] The most complex patients, who ideally are seen within a few days of discharge, are the least likely to have received the discharge summary at the first postdischarge visit.

Although it seems intuitively obvious that more timely communication of discharge summaries should lead to better outcomes, especially lower readmission rates, few studies have examined this issue, and the findings have not been consistent.[2, 3, 4, 5] Is it possible that physicians and other members of the healthcare team often communicate with each other through telephone calls and text messaging, especially about the sickest patients? If so, timely discharge summaries could have a small marginal effect on outcomes. Therefore, the study in this issue of the Journal of Hospital Medicine by Hoyer and colleagues is a welcome addition to the literature.[6] They found that discharge summary completion 3 or more days after discharge was associated with an adjusted odds ratio of 1.09, and the odds ratio increased with every additional 3‐day delay in completion.

It is possible that the analysis by Hoyer et al. underestimated the benefit of timely discharge summaries. To achieve full benefit, the discharge summary must be completed, accurately delivered, read by the receiving provider, and used at the first follow‐up visit. Their claims‐based analysis did not contains these latter elements, which would bias their results toward the null hypothesis. Future studies should examine how receipt of a summary, as opposed to transmission, is associated with postdischarge outcomes.

In subgroup analyses, no associations between discharge summary timeliness and readmissions were found for patients cared for on the gynecology‐obstetrics and surgical sciences services. Although caution is always needed when interpreting subgroup analyses, it is possible that the lack of association is attributable to the relatively acute conditions of many patients on these services, the relative provider continuity that persists in surgical disciplines, or whether these disciplines use other means of communication more frequently (eg, postdischarge phone calls among providers), mitigating the impact of the written discharge summary. Additional studies are needed to examine these issues. In addition, studies should examine how community or social factors might attenuate the benefit of timely communication, and explore the effect of discharge summaries on outcomes for patients admitted to an observation level of care, which is increasingly common and for which discharge summaries are less likely to be required.

The findings of the study by Hoyer et al. support proposed federal legislationthe Improving Medicare Post‐Acute Care Transformation Act of 2014. The proposed rule for discharge planning would change the Medicare Conditions of Participation to require transmission of discharge information, including the discharge summary, within 48 hours of discharge (https://federalregister.gov/a/2015‐27840A).[7] If enacted, this rule could substantially improve the timely availability of discharge information following care transition.

Fortunately, the work of preparing and transmitting the discharge summary is already part of the physician workflow, albeit often delayed. This traditional means of communication could even remain unchanged in form, if the order of the workflow could be altered in terms of timeliness, and no additional work would be created. With the hospitalization fresher in memory at the time of discharge, work might even be reduced. This efficiency presents a reasonable and immediately actionable appeal to providers.

The challenge to providers and systems remains to refine the quality and efficiency of communication and to move health communication into the 21st century. Tremendous potential exists for interactive communication among providers at discharge, which will not only build the quality of information delivered, but possibly also the qualitative experience of communication, building relationships in our increasingly complex and fragmented delivery networks. This may be a disappointment to the manufacturers of fax machines, but it will be a welcome improvement for caregivers and patients.

In July 2003, as a fresh intern, I was introduced to care transitions and our tool for information transfer at hospital dischargethe fax machine. After writing our discharge order and discharge prescriptions, the team would compose the discharge summary and transmit the document via fax. I asked my resident where these faxes were going, because they were all sent to the same number in the hospital. Humorously, he did not know. Summaries were completed within days, or sometimes weeks, of discharge and faxed to a mysterious destination for filing and presumably for dissemination to outside providers. The message was clear to me that discharge summaries were not very useful or important, and they were definitely not seen as a critical part of the care‐transition process.

This attitude toward the discharge summary is not surprising. Historically, when physicians cared for their patients prior to, during, and after hospitalization, the goal of the discharge summary was to document patients' care for hospital records. It was not critical as a communication tool unless a patient was being transferred to another healthcare facility and a new care team. However, that all changed with decreasing hospital length of stay, the contemporaneous rise in postacute care discharges, the rise of the hospitalist care model, and the resulting transition of care from hospitalist to outpatient physician. Clear, rapid completion and communication of discharge summaries became essential for safe transitions in care.

The lack of focus on the discharge summary as a communication tool is reflected in regulations and standards of accreditation bodies. In 1986, the Medicare Condition of Participation required that inpatient records be completed within 30 days of discharge. Despite all of the changes in healthcare, the 30‐day requirement for discharge summary completion has persisted, often as a medical staff requirement. Similarly, The Joint Commission requires that discharge summaries include 6 components (reason for hospitalization, findings, treatment provided, discharge condition, instructions, and physician signature) but does not provide a timeframe. As a result of this lack of emphasis on timely completion of discharge summaries, studies have shown that although summaries usually include core elements, they are not completed in a timely fashion. Consequently, most postdischarge visits occur without the benefit of a discharge summary.[1] The most complex patients, who ideally are seen within a few days of discharge, are the least likely to have received the discharge summary at the first postdischarge visit.

Although it seems intuitively obvious that more timely communication of discharge summaries should lead to better outcomes, especially lower readmission rates, few studies have examined this issue, and the findings have not been consistent.[2, 3, 4, 5] Is it possible that physicians and other members of the healthcare team often communicate with each other through telephone calls and text messaging, especially about the sickest patients? If so, timely discharge summaries could have a small marginal effect on outcomes. Therefore, the study in this issue of the Journal of Hospital Medicine by Hoyer and colleagues is a welcome addition to the literature.[6] They found that discharge summary completion 3 or more days after discharge was associated with an adjusted odds ratio of 1.09, and the odds ratio increased with every additional 3‐day delay in completion.

It is possible that the analysis by Hoyer et al. underestimated the benefit of timely discharge summaries. To achieve full benefit, the discharge summary must be completed, accurately delivered, read by the receiving provider, and used at the first follow‐up visit. Their claims‐based analysis did not contains these latter elements, which would bias their results toward the null hypothesis. Future studies should examine how receipt of a summary, as opposed to transmission, is associated with postdischarge outcomes.

In subgroup analyses, no associations between discharge summary timeliness and readmissions were found for patients cared for on the gynecology‐obstetrics and surgical sciences services. Although caution is always needed when interpreting subgroup analyses, it is possible that the lack of association is attributable to the relatively acute conditions of many patients on these services, the relative provider continuity that persists in surgical disciplines, or whether these disciplines use other means of communication more frequently (eg, postdischarge phone calls among providers), mitigating the impact of the written discharge summary. Additional studies are needed to examine these issues. In addition, studies should examine how community or social factors might attenuate the benefit of timely communication, and explore the effect of discharge summaries on outcomes for patients admitted to an observation level of care, which is increasingly common and for which discharge summaries are less likely to be required.

The findings of the study by Hoyer et al. support proposed federal legislationthe Improving Medicare Post‐Acute Care Transformation Act of 2014. The proposed rule for discharge planning would change the Medicare Conditions of Participation to require transmission of discharge information, including the discharge summary, within 48 hours of discharge (https://federalregister.gov/a/2015‐27840A).[7] If enacted, this rule could substantially improve the timely availability of discharge information following care transition.

Fortunately, the work of preparing and transmitting the discharge summary is already part of the physician workflow, albeit often delayed. This traditional means of communication could even remain unchanged in form, if the order of the workflow could be altered in terms of timeliness, and no additional work would be created. With the hospitalization fresher in memory at the time of discharge, work might even be reduced. This efficiency presents a reasonable and immediately actionable appeal to providers.

The challenge to providers and systems remains to refine the quality and efficiency of communication and to move health communication into the 21st century. Tremendous potential exists for interactive communication among providers at discharge, which will not only build the quality of information delivered, but possibly also the qualitative experience of communication, building relationships in our increasingly complex and fragmented delivery networks. This may be a disappointment to the manufacturers of fax machines, but it will be a welcome improvement for caregivers and patients.

Across the continuum of care, the discharge summary is a critical tool for communication among care providers.[1] In the United States, the Joint Commission policies mandate that all hospital providers complete a discharge summary for patients with specific components to foster effective communication with future providers.[2] Because outpatient providers and emergency physicians rely on clinical information in the discharge summary to ensure appropriate postdischarge continuity of care, timely documentation is potentially an essential aspect of readmission reduction initiatives.[3, 4, 5] Prior reports indicate that poor discharge documentation of follow‐up plan‐of‐care increases the risk of hospitalization, whereas structured instructions, patient education, and direct communications with primary care physicians (PCPs) reduce repeat hospital visits.[6, 7, 8, 9] However, the current literature is limited in its narrow focus on the contents of discharge summaries, considered only same‐hospital readmissions, or considered readmissions within 3 months of discharge.[10, 11, 12, 13] Moreover, some prior research has suggested no association between discharge summary timeliness with readmission,[12, 13, 14] whereas another study did find a relationship,[15] hence the need to study this further is important. Filling this gap in knowledge could provide an avenue to track and improve quality of patient care, as delays in discharge summaries have been linked with pot‐discharge adverse outcomes and patient safety concerns.[15, 16, 17, 18] Because readmissions often occur soon after discharge, having timely discharge summaries may be particularly important to outcomes.[19, 20]

This research began under the framework of evaluating a bundle of care coordination strategies that were implemented at the Johns Hopkins Health System. These strategies were informed by the early Centers for Medicare and Medicaid Services (CMS) demonstration projects and other best practices that have been documented in the literature to improve utilization and improve communication during transitions of care.[21, 22, 23, 24, 25] Later they were augmented through a contract with the Center of Medicare and Medicaid Innovation to improve access to healthcare services and improve patient outcomes through improved care coordination processes. One of the domains our institution has increased efforts to improve is in provider handoffs. Toward that goal, we have worked to disentangle the effects of different factors of provider‐to‐provider communication that may influence readmissions.[26] For example, effective written provider handoffs in the form of accurate and timely discharge summaries was considered a key care coordination component of this program, but there was institutional resistance to endorsing an expectation that discharge summary turnaround should be shortened. To build a case for this concept, we sought to test the hypothesis that, at our hospital, longer time to complete hospital discharge summaries was associated with increased readmission rates. Unique to this analysis is that, in the state of Maryland, there is statewide reporting of readmissions, so we were able to account for intra‐ and interhospital readmissions for an all‐payer population. The authors anticipated that findings from this study would help inform discharge quality‐improvement initiatives and reemphasize the importance of timely discharge documentation across all disciplines as part of quality patient care.

METHODS

RESULTS

Association Between Days to Complete the Discharge Summary and Readmission

After hospital discharge, median (IQR) number of days to complete discharge summaries was 8 (416) days. After hospital discharge, median (IQR) number of days to complete discharge summaries and the number of days from discharge to readmission was 8 (416) and 11 (519) days, respectively (P < 0.001). Six thousand one hundred one patients (42.8%) were readmitted before their discharge summary was completed. The median (IQR) days to complete discharge summaries by hospital service in order from shortest to longest was: oncology, 6 (212) days; surgical sciences, 6 (312) days; pediatrics, 7 (315) days; gynecologyobstetrics, 8 (415) days; medicine, 9 (420) days; neurosciences, 12 (621) days.

When we divided the number of days to complete the discharge summary into deciles (02, 2.13, 3.14, 4.16, 6.18, 8.210, 10.114, 14.119, 19.130, >30), a longer number of days to complete discharge summaries had higher unadjusted and adjusted readmission rates (Figure 1). In unadjusted analysis, Table 2 shows that older age, male sex, African American race, oncological versus medicine hospital service, discharge location, longer LOS, higher APRDRG‐SOI expected readmission rate, and higher AHRQ Comorbidity Index were associated with readmission. Days to complete the discharge summary >3 days versus 3 days was associated with a higher readmission rate, with an unadjusted odds ratio (OR) and 95% confidence interval (CI) of 1.09 (95% CI: 1.04 to 1.13, P < 0.001).

Table 2.Association Between Patient Characteristics, Discharge Summary Completion >3 Days, and 30‐Day Readmission Status

Characteristic	Bivariable Analysis*		Multivariable Analysis*
	OR (95% CI)	P Value	OR (95% CI)	P Value
NOTE: Abbreviations: AHRQ, Agency for Healthcare Research and Quality; APRDRG, All‐PayerRefined Diagnosis‐Related Group; CI, confidence interval; OR, odds ratio; SNF, skilled nursing facility; SOI, severity of illness. *Calculated using logistic regression analysis.
Age, 10 y	1.09 (1.08 to 1.09)	<0.001	0.97 (0.95 to 0.98)	<0.001
Male	1.13 (1.09 to 1.17)	<0.001	1.01 (0.97 to 1.05)	0.76
Race
Caucasian	Referent		Referent
African American	1.21 (1.17 to 1.26)	<0.001	1.01 (0.96 to 1.05)	0.74
Other	0.84 (0.79 to 0.90)	<0.001	0.92 (0.86 to 0.98)	0.01
Payer
Medicare	Referent		Referent
Medicaid	0.74 (0.70 to 0.77)	<0.001	1.03 (0.97 to 1.09)	0.42
Other	0.57 (0.55 to 0.60)	<0.001	0.86 (0.82 to 0.91)	<0.001
Hospital service
Medicine	Referent		Referent
Gynecologyobstetrics	0.18 (0.16 to 0.20)	<0.001	0.50 (0.45 to 0.56)	<0.001
Neurosciences	0.43 (0.40 to 0.46)	<0.001	0.76 (0.70 to 0.82)	<0.001
Oncology	1.14 (1.07 to 1.22)	<0.001	1.18 (1.10 to 1.28)	<0.001
Pediatrics	0.54 (0.51 to 0.57)	<0.001	0.77 (0.71 to 0.83)	<0.001
Surgical sciences	0.57 (0.54 to 0.60)	<0.001	0.92 (0.87 to 0.97)	0.002
Discharge location
Home			Referent
Facility (SNF, rehabilitation facility)	1.90 (1.77 to 2.03)	<0.001	1.11 (1.02 to 1.19)	0.009
Home with homecare or hospice	1.73 (1.64 to 1.83)	<0.001	1.26 (1.19 to 1.34)	<0.001
Other	1.89 (1.78 to 2.00)	<0.001	1.25 (1.18 to 1.34)	<0.001
Length of stay, d	1.03 (1.02 to 1.03)	<0.001	1.00 (1.00 to 1.01)	<0.001
APRDRG‐SOI expected readmission rate, %	1.08 (1.07 to 1.08)	<0.001	1.06 (1.06 to 1.06)	<0.001
AHRQ Comorbidity Index (1 point)	1.27 (1.26 to 1.28)	<0.001	1.11 (1.09 to 1.12)	<0.001
Discharge summary completed >3 days	1.09 (1.04 to 1.14)	<0.001	1.09 (1.05 to 1.14)	<0.001

Figure 1

DISCUSSION

In this single‐center retrospective analysis, the number of days to complete the discharge summary was significantly associated with readmissions after hospitalization. This association was independent of age, gender, comorbidity index, payer, discharge location, length of hospital stay, expected readmission rate based on diagnosis and severity of illness, and all hospital services. The odds of readmission for patients with delayed discharge summaries was small but significant. This is important in the current landscape of readmissions, particularly for institutions who are challenged to reduce readmission rates, and a small relative difference in readmissions may be the difference between getting penalized or not. In the context of prior studies, the results highlight the role of timely discharge summary as an under‐recognized metric, which may be a valid litmus test for care coordination. The findings also emphasize the potential of early summaries to expedite communication and to help facilitate quality of patient care. Hence, the study results extend the literature examining the relationship of delay in discharge summary with unfavorable patient outcomes.[15, 32]

In contrast to prior reports with limited focus on same‐hospital readmissions,[18, 33, 34, 35] readmissions beyond 30 days,[12] or focused on a specific patient population,[13, 36] this study evaluates both intra‐ and interhospital 30‐day readmissions in Maryland in an all‐payer, multi‐institution, diverse patient population. Additionally, prior research is conflicting with respect to whether timely discharges summaries are significantly associated with increased hospital readmissions.[12, 13, 14, 15] Although it is not surprising that inadequate care during hospitalization could result in readmissions, the role of discharge summaries remain underappreciated. Having a timely discharge summary may not always prevent readmissions, but our study showed that 43% of readmission occurred before the discharge summary completion. Not having a completed discharge summary at the time of readmission may have been a driver for the positive association between timely completion and 30‐day readmission we observed. This study highlights that delay in the discharge summary could be a marker of poor transitions of care, because suboptimal dissemination of critical information to care providers may result in discontinuity of patient care posthospitalization.

A plausible mechanism of the association between discharge summary delays and readmissions could be the provision of collateral information, which may potentially alter the threshold for readmissions. For example, in the emergency room/emergency department (ER/ED) setting, discharge summaries may help with preventable readmissions. For patients who present repeatedly with the same complaint, timely summaries to ER/ED providers may help reframe the patient complaints, such as patient has concern X, which was previously identified to be related to diagnosis Y. As others have shown, the content of discharge summaries, format, and accessibility (electronic vs paper chart), as well as timely distribution of summaries, are key factors that impact quality outcomes.[2, 12, 15, 37, 38] By detailing prior hospital information (ie, discharge medications, prior presentations, tests completed), summaries could help prevent errors in medication dosing, reduce unnecessary testing, and help facilitate admission triage. Summaries may have information regarding a new diagnosis such as the results of an endoscopic evaluation that revealed the source of occult gastrointestinal bleeding, which could help contextualize a complaint of repeat melena and redirect goals of care. Discussions of goals of care in the discharge summary may guide primary providers in continued care management plans.

Our study findings underscore a positive correlation between late discharge summaries and readmissions. However, the extent that this is a causal relationship is unclear; the association of delay in days to complete the discharge summary with readmission may be an epiphenomenon related to processes related to quality of clinical care. For example, delays in discharge summary completion could be a marker of other system issues, such as a stressed work environment. It is possible that providers who fail to complete timely discharge summaries may also fail to do other important functions related to transitions of care and care coordination. However, even if this is so, timely discharge summaries could become a focal point for discussion for optimization of care transitions. A discharge summary could be delayed because the patient has already been readmitted before the summary was distributed, thus making that original summary less relevant. Delays could also be a reflection of the data complexity for patients with longer hospital stays. This is supported by the small but significant relationship between LOS and days to complete the discharge summary in this study. Lastly, delays in discharge summary completion may also be a proxy of provider communication and can reflect the culture of communication at the institution.

Although unplanned hospital readmission is an important outcome, many readmissions may be related to other factors such as disease progression, rather than late summaries or the lack of postdischarge communication. For instance, prior reports did not find any association between the PCP seeing the discharge summaries or direct communications with the PCP and 30‐day clinical outcomes for readmission and death.[26, 39] However, these studies were limited in their use of self‐reported handoffs, did not measure quality of information transfer, and failed to capture a broader audience beyond the PCP, such as ED physicians or specialists.

Our results suggest that the relationship between days to complete discharge summaries and 30‐day readmissions may vary depending on whether the hospitalization is primarily surgical/procedural versus medical treatment. A recent study found that most readmissions after surgery were associated with new complications related to the procedure and not exacerbation of prior index hospitalization complications.[40] Hence, treatment for common causes of hospital readmissions after surgical or gynecological procedures, such as wound infections, acute anemia, ileus, or dehydration, may not necessarily require a completed discharge summary for appropriate management. However, we caution extending this finding to clinical practice before further studies are conducted on specific procedures and in different clinical settings.

Results from this study also support institutional policies that specify the need for practitioners to complete discharge summaries contemporaneously, such as at the time of discharge or within a couple of days. Unlike other forms of communication that are optional, discharge summaries are required, so we recommend that practitioners be held accountable for short turnaround times. For example, providers could be graded and rated on timely completions of discharge summaries, among other performance variables. Anecdotally at our institutions, we have heard from practitioners that it takes less time to complete them when you do them on the day of discharge, because the hospitalization course is fresher in their mind and they have to wade through less information in the medical record to complete an accurate discharge summary. To this point, a barrier to on‐time completion is that providers may have misconceptions about what is really vital information to convey to the next provider. In agreement with past research and in the era of the electronic medical record system, we recommend that the discharge summary should be a quick synthesis of key findings that incorporates only the important elements, such as why the patient was hospitalized, what were key findings and key responses to therapy, what is pending at the time of discharge, what medications the patient is currently taking, and what are the follow‐up plans, rather than a lengthy expose of all the findings.[13, 36, 41, 42]

Lastly, our study results should be taken in the context of its limitations. As a single‐center study, findings may lack generalizability. In particular, the results may not generalize to hospitals that lack access to statewide reporting. We were also not able to assess readmission for patients who may have been readmitted to a hospital outside of Maryland. Although we adjusted for pertinent variables such as age, gender, healthcare payer, hospital service, comorbidity index, discharge location, LOS, and expected readmission rates, there may be other relevant confounders that we failed to capture or measure optimally. Median days to complete the discharge summary in this study was 8 days, which is longer than practices at other institutions, and may also limit this study's generalizability.[15, 36, 42] However, prior research supports our findings,[15] and a systematic review found that only 29% and 52% of discharge summaries were completed by 2 weeks and 4 weeks, respectively.[9] Finally, as noted above and perhaps most important, it is possible that discharge summary turnaround time does not in itself causally impact readmissions, but rather reflects an underlying commitment of the inpatient team to effectively coordinate care following hospital discharge.

CONCLUSION

In sum, this study delineates an underappreciated but important relationship of timely discharge summary completion and readmission outcomes. The discharge summary may be a relevant metric reflecting quality of patient care. Healthcare providers may begin to target timely discharge summaries as a potential focal point of quality‐improvement projects with the goal to facilitate better patient outcomes.

Across the continuum of care, the discharge summary is a critical tool for communication among care providers.[1] In the United States, the Joint Commission policies mandate that all hospital providers complete a discharge summary for patients with specific components to foster effective communication with future providers.[2] Because outpatient providers and emergency physicians rely on clinical information in the discharge summary to ensure appropriate postdischarge continuity of care, timely documentation is potentially an essential aspect of readmission reduction initiatives.[3, 4, 5] Prior reports indicate that poor discharge documentation of follow‐up plan‐of‐care increases the risk of hospitalization, whereas structured instructions, patient education, and direct communications with primary care physicians (PCPs) reduce repeat hospital visits.[6, 7, 8, 9] However, the current literature is limited in its narrow focus on the contents of discharge summaries, considered only same‐hospital readmissions, or considered readmissions within 3 months of discharge.[10, 11, 12, 13] Moreover, some prior research has suggested no association between discharge summary timeliness with readmission,[12, 13, 14] whereas another study did find a relationship,[15] hence the need to study this further is important. Filling this gap in knowledge could provide an avenue to track and improve quality of patient care, as delays in discharge summaries have been linked with pot‐discharge adverse outcomes and patient safety concerns.[15, 16, 17, 18] Because readmissions often occur soon after discharge, having timely discharge summaries may be particularly important to outcomes.[19, 20]

This research began under the framework of evaluating a bundle of care coordination strategies that were implemented at the Johns Hopkins Health System. These strategies were informed by the early Centers for Medicare and Medicaid Services (CMS) demonstration projects and other best practices that have been documented in the literature to improve utilization and improve communication during transitions of care.[21, 22, 23, 24, 25] Later they were augmented through a contract with the Center of Medicare and Medicaid Innovation to improve access to healthcare services and improve patient outcomes through improved care coordination processes. One of the domains our institution has increased efforts to improve is in provider handoffs. Toward that goal, we have worked to disentangle the effects of different factors of provider‐to‐provider communication that may influence readmissions.[26] For example, effective written provider handoffs in the form of accurate and timely discharge summaries was considered a key care coordination component of this program, but there was institutional resistance to endorsing an expectation that discharge summary turnaround should be shortened. To build a case for this concept, we sought to test the hypothesis that, at our hospital, longer time to complete hospital discharge summaries was associated with increased readmission rates. Unique to this analysis is that, in the state of Maryland, there is statewide reporting of readmissions, so we were able to account for intra‐ and interhospital readmissions for an all‐payer population. The authors anticipated that findings from this study would help inform discharge quality‐improvement initiatives and reemphasize the importance of timely discharge documentation across all disciplines as part of quality patient care.

METHODS

RESULTS

Association Between Days to Complete the Discharge Summary and Readmission

After hospital discharge, median (IQR) number of days to complete discharge summaries was 8 (416) days. After hospital discharge, median (IQR) number of days to complete discharge summaries and the number of days from discharge to readmission was 8 (416) and 11 (519) days, respectively (P < 0.001). Six thousand one hundred one patients (42.8%) were readmitted before their discharge summary was completed. The median (IQR) days to complete discharge summaries by hospital service in order from shortest to longest was: oncology, 6 (212) days; surgical sciences, 6 (312) days; pediatrics, 7 (315) days; gynecologyobstetrics, 8 (415) days; medicine, 9 (420) days; neurosciences, 12 (621) days.

When we divided the number of days to complete the discharge summary into deciles (02, 2.13, 3.14, 4.16, 6.18, 8.210, 10.114, 14.119, 19.130, >30), a longer number of days to complete discharge summaries had higher unadjusted and adjusted readmission rates (Figure 1). In unadjusted analysis, Table 2 shows that older age, male sex, African American race, oncological versus medicine hospital service, discharge location, longer LOS, higher APRDRG‐SOI expected readmission rate, and higher AHRQ Comorbidity Index were associated with readmission. Days to complete the discharge summary >3 days versus 3 days was associated with a higher readmission rate, with an unadjusted odds ratio (OR) and 95% confidence interval (CI) of 1.09 (95% CI: 1.04 to 1.13, P < 0.001).

Table 2.Association Between Patient Characteristics, Discharge Summary Completion >3 Days, and 30‐Day Readmission Status

Characteristic	Bivariable Analysis*		Multivariable Analysis*
	OR (95% CI)	P Value	OR (95% CI)	P Value
NOTE: Abbreviations: AHRQ, Agency for Healthcare Research and Quality; APRDRG, All‐PayerRefined Diagnosis‐Related Group; CI, confidence interval; OR, odds ratio; SNF, skilled nursing facility; SOI, severity of illness. *Calculated using logistic regression analysis.
Age, 10 y	1.09 (1.08 to 1.09)	<0.001	0.97 (0.95 to 0.98)	<0.001
Male	1.13 (1.09 to 1.17)	<0.001	1.01 (0.97 to 1.05)	0.76
Race
Caucasian	Referent		Referent
African American	1.21 (1.17 to 1.26)	<0.001	1.01 (0.96 to 1.05)	0.74
Other	0.84 (0.79 to 0.90)	<0.001	0.92 (0.86 to 0.98)	0.01
Payer
Medicare	Referent		Referent
Medicaid	0.74 (0.70 to 0.77)	<0.001	1.03 (0.97 to 1.09)	0.42
Other	0.57 (0.55 to 0.60)	<0.001	0.86 (0.82 to 0.91)	<0.001
Hospital service
Medicine	Referent		Referent
Gynecologyobstetrics	0.18 (0.16 to 0.20)	<0.001	0.50 (0.45 to 0.56)	<0.001
Neurosciences	0.43 (0.40 to 0.46)	<0.001	0.76 (0.70 to 0.82)	<0.001
Oncology	1.14 (1.07 to 1.22)	<0.001	1.18 (1.10 to 1.28)	<0.001
Pediatrics	0.54 (0.51 to 0.57)	<0.001	0.77 (0.71 to 0.83)	<0.001
Surgical sciences	0.57 (0.54 to 0.60)	<0.001	0.92 (0.87 to 0.97)	0.002
Discharge location
Home			Referent
Facility (SNF, rehabilitation facility)	1.90 (1.77 to 2.03)	<0.001	1.11 (1.02 to 1.19)	0.009
Home with homecare or hospice	1.73 (1.64 to 1.83)	<0.001	1.26 (1.19 to 1.34)	<0.001
Other	1.89 (1.78 to 2.00)	<0.001	1.25 (1.18 to 1.34)	<0.001
Length of stay, d	1.03 (1.02 to 1.03)	<0.001	1.00 (1.00 to 1.01)	<0.001
APRDRG‐SOI expected readmission rate, %	1.08 (1.07 to 1.08)	<0.001	1.06 (1.06 to 1.06)	<0.001
AHRQ Comorbidity Index (1 point)	1.27 (1.26 to 1.28)	<0.001	1.11 (1.09 to 1.12)	<0.001
Discharge summary completed >3 days	1.09 (1.04 to 1.14)	<0.001	1.09 (1.05 to 1.14)	<0.001

Figure 1

DISCUSSION

In this single‐center retrospective analysis, the number of days to complete the discharge summary was significantly associated with readmissions after hospitalization. This association was independent of age, gender, comorbidity index, payer, discharge location, length of hospital stay, expected readmission rate based on diagnosis and severity of illness, and all hospital services. The odds of readmission for patients with delayed discharge summaries was small but significant. This is important in the current landscape of readmissions, particularly for institutions who are challenged to reduce readmission rates, and a small relative difference in readmissions may be the difference between getting penalized or not. In the context of prior studies, the results highlight the role of timely discharge summary as an under‐recognized metric, which may be a valid litmus test for care coordination. The findings also emphasize the potential of early summaries to expedite communication and to help facilitate quality of patient care. Hence, the study results extend the literature examining the relationship of delay in discharge summary with unfavorable patient outcomes.[15, 32]

In contrast to prior reports with limited focus on same‐hospital readmissions,[18, 33, 34, 35] readmissions beyond 30 days,[12] or focused on a specific patient population,[13, 36] this study evaluates both intra‐ and interhospital 30‐day readmissions in Maryland in an all‐payer, multi‐institution, diverse patient population. Additionally, prior research is conflicting with respect to whether timely discharges summaries are significantly associated with increased hospital readmissions.[12, 13, 14, 15] Although it is not surprising that inadequate care during hospitalization could result in readmissions, the role of discharge summaries remain underappreciated. Having a timely discharge summary may not always prevent readmissions, but our study showed that 43% of readmission occurred before the discharge summary completion. Not having a completed discharge summary at the time of readmission may have been a driver for the positive association between timely completion and 30‐day readmission we observed. This study highlights that delay in the discharge summary could be a marker of poor transitions of care, because suboptimal dissemination of critical information to care providers may result in discontinuity of patient care posthospitalization.

A plausible mechanism of the association between discharge summary delays and readmissions could be the provision of collateral information, which may potentially alter the threshold for readmissions. For example, in the emergency room/emergency department (ER/ED) setting, discharge summaries may help with preventable readmissions. For patients who present repeatedly with the same complaint, timely summaries to ER/ED providers may help reframe the patient complaints, such as patient has concern X, which was previously identified to be related to diagnosis Y. As others have shown, the content of discharge summaries, format, and accessibility (electronic vs paper chart), as well as timely distribution of summaries, are key factors that impact quality outcomes.[2, 12, 15, 37, 38] By detailing prior hospital information (ie, discharge medications, prior presentations, tests completed), summaries could help prevent errors in medication dosing, reduce unnecessary testing, and help facilitate admission triage. Summaries may have information regarding a new diagnosis such as the results of an endoscopic evaluation that revealed the source of occult gastrointestinal bleeding, which could help contextualize a complaint of repeat melena and redirect goals of care. Discussions of goals of care in the discharge summary may guide primary providers in continued care management plans.

Our study findings underscore a positive correlation between late discharge summaries and readmissions. However, the extent that this is a causal relationship is unclear; the association of delay in days to complete the discharge summary with readmission may be an epiphenomenon related to processes related to quality of clinical care. For example, delays in discharge summary completion could be a marker of other system issues, such as a stressed work environment. It is possible that providers who fail to complete timely discharge summaries may also fail to do other important functions related to transitions of care and care coordination. However, even if this is so, timely discharge summaries could become a focal point for discussion for optimization of care transitions. A discharge summary could be delayed because the patient has already been readmitted before the summary was distributed, thus making that original summary less relevant. Delays could also be a reflection of the data complexity for patients with longer hospital stays. This is supported by the small but significant relationship between LOS and days to complete the discharge summary in this study. Lastly, delays in discharge summary completion may also be a proxy of provider communication and can reflect the culture of communication at the institution.

Although unplanned hospital readmission is an important outcome, many readmissions may be related to other factors such as disease progression, rather than late summaries or the lack of postdischarge communication. For instance, prior reports did not find any association between the PCP seeing the discharge summaries or direct communications with the PCP and 30‐day clinical outcomes for readmission and death.[26, 39] However, these studies were limited in their use of self‐reported handoffs, did not measure quality of information transfer, and failed to capture a broader audience beyond the PCP, such as ED physicians or specialists.

Our results suggest that the relationship between days to complete discharge summaries and 30‐day readmissions may vary depending on whether the hospitalization is primarily surgical/procedural versus medical treatment. A recent study found that most readmissions after surgery were associated with new complications related to the procedure and not exacerbation of prior index hospitalization complications.[40] Hence, treatment for common causes of hospital readmissions after surgical or gynecological procedures, such as wound infections, acute anemia, ileus, or dehydration, may not necessarily require a completed discharge summary for appropriate management. However, we caution extending this finding to clinical practice before further studies are conducted on specific procedures and in different clinical settings.

Results from this study also support institutional policies that specify the need for practitioners to complete discharge summaries contemporaneously, such as at the time of discharge or within a couple of days. Unlike other forms of communication that are optional, discharge summaries are required, so we recommend that practitioners be held accountable for short turnaround times. For example, providers could be graded and rated on timely completions of discharge summaries, among other performance variables. Anecdotally at our institutions, we have heard from practitioners that it takes less time to complete them when you do them on the day of discharge, because the hospitalization course is fresher in their mind and they have to wade through less information in the medical record to complete an accurate discharge summary. To this point, a barrier to on‐time completion is that providers may have misconceptions about what is really vital information to convey to the next provider. In agreement with past research and in the era of the electronic medical record system, we recommend that the discharge summary should be a quick synthesis of key findings that incorporates only the important elements, such as why the patient was hospitalized, what were key findings and key responses to therapy, what is pending at the time of discharge, what medications the patient is currently taking, and what are the follow‐up plans, rather than a lengthy expose of all the findings.[13, 36, 41, 42]

Lastly, our study results should be taken in the context of its limitations. As a single‐center study, findings may lack generalizability. In particular, the results may not generalize to hospitals that lack access to statewide reporting. We were also not able to assess readmission for patients who may have been readmitted to a hospital outside of Maryland. Although we adjusted for pertinent variables such as age, gender, healthcare payer, hospital service, comorbidity index, discharge location, LOS, and expected readmission rates, there may be other relevant confounders that we failed to capture or measure optimally. Median days to complete the discharge summary in this study was 8 days, which is longer than practices at other institutions, and may also limit this study's generalizability.[15, 36, 42] However, prior research supports our findings,[15] and a systematic review found that only 29% and 52% of discharge summaries were completed by 2 weeks and 4 weeks, respectively.[9] Finally, as noted above and perhaps most important, it is possible that discharge summary turnaround time does not in itself causally impact readmissions, but rather reflects an underlying commitment of the inpatient team to effectively coordinate care following hospital discharge.

CONCLUSION

In sum, this study delineates an underappreciated but important relationship of timely discharge summary completion and readmission outcomes. The discharge summary may be a relevant metric reflecting quality of patient care. Healthcare providers may begin to target timely discharge summaries as a potential focal point of quality‐improvement projects with the goal to facilitate better patient outcomes.

Across the continuum of care, the discharge summary is a critical tool for communication among care providers.[1] In the United States, the Joint Commission policies mandate that all hospital providers complete a discharge summary for patients with specific components to foster effective communication with future providers.[2] Because outpatient providers and emergency physicians rely on clinical information in the discharge summary to ensure appropriate postdischarge continuity of care, timely documentation is potentially an essential aspect of readmission reduction initiatives.[3, 4, 5] Prior reports indicate that poor discharge documentation of follow‐up plan‐of‐care increases the risk of hospitalization, whereas structured instructions, patient education, and direct communications with primary care physicians (PCPs) reduce repeat hospital visits.[6, 7, 8, 9] However, the current literature is limited in its narrow focus on the contents of discharge summaries, considered only same‐hospital readmissions, or considered readmissions within 3 months of discharge.[10, 11, 12, 13] Moreover, some prior research has suggested no association between discharge summary timeliness with readmission,[12, 13, 14] whereas another study did find a relationship,[15] hence the need to study this further is important. Filling this gap in knowledge could provide an avenue to track and improve quality of patient care, as delays in discharge summaries have been linked with pot‐discharge adverse outcomes and patient safety concerns.[15, 16, 17, 18] Because readmissions often occur soon after discharge, having timely discharge summaries may be particularly important to outcomes.[19, 20]

This research began under the framework of evaluating a bundle of care coordination strategies that were implemented at the Johns Hopkins Health System. These strategies were informed by the early Centers for Medicare and Medicaid Services (CMS) demonstration projects and other best practices that have been documented in the literature to improve utilization and improve communication during transitions of care.[21, 22, 23, 24, 25] Later they were augmented through a contract with the Center of Medicare and Medicaid Innovation to improve access to healthcare services and improve patient outcomes through improved care coordination processes. One of the domains our institution has increased efforts to improve is in provider handoffs. Toward that goal, we have worked to disentangle the effects of different factors of provider‐to‐provider communication that may influence readmissions.[26] For example, effective written provider handoffs in the form of accurate and timely discharge summaries was considered a key care coordination component of this program, but there was institutional resistance to endorsing an expectation that discharge summary turnaround should be shortened. To build a case for this concept, we sought to test the hypothesis that, at our hospital, longer time to complete hospital discharge summaries was associated with increased readmission rates. Unique to this analysis is that, in the state of Maryland, there is statewide reporting of readmissions, so we were able to account for intra‐ and interhospital readmissions for an all‐payer population. The authors anticipated that findings from this study would help inform discharge quality‐improvement initiatives and reemphasize the importance of timely discharge documentation across all disciplines as part of quality patient care.

METHODS

RESULTS

Association Between Days to Complete the Discharge Summary and Readmission

After hospital discharge, median (IQR) number of days to complete discharge summaries was 8 (416) days. After hospital discharge, median (IQR) number of days to complete discharge summaries and the number of days from discharge to readmission was 8 (416) and 11 (519) days, respectively (P < 0.001). Six thousand one hundred one patients (42.8%) were readmitted before their discharge summary was completed. The median (IQR) days to complete discharge summaries by hospital service in order from shortest to longest was: oncology, 6 (212) days; surgical sciences, 6 (312) days; pediatrics, 7 (315) days; gynecologyobstetrics, 8 (415) days; medicine, 9 (420) days; neurosciences, 12 (621) days.

When we divided the number of days to complete the discharge summary into deciles (02, 2.13, 3.14, 4.16, 6.18, 8.210, 10.114, 14.119, 19.130, >30), a longer number of days to complete discharge summaries had higher unadjusted and adjusted readmission rates (Figure 1). In unadjusted analysis, Table 2 shows that older age, male sex, African American race, oncological versus medicine hospital service, discharge location, longer LOS, higher APRDRG‐SOI expected readmission rate, and higher AHRQ Comorbidity Index were associated with readmission. Days to complete the discharge summary >3 days versus 3 days was associated with a higher readmission rate, with an unadjusted odds ratio (OR) and 95% confidence interval (CI) of 1.09 (95% CI: 1.04 to 1.13, P < 0.001).

Table 2.Association Between Patient Characteristics, Discharge Summary Completion >3 Days, and 30‐Day Readmission Status

Characteristic	Bivariable Analysis*		Multivariable Analysis*
	OR (95% CI)	P Value	OR (95% CI)	P Value
NOTE: Abbreviations: AHRQ, Agency for Healthcare Research and Quality; APRDRG, All‐PayerRefined Diagnosis‐Related Group; CI, confidence interval; OR, odds ratio; SNF, skilled nursing facility; SOI, severity of illness. *Calculated using logistic regression analysis.
Age, 10 y	1.09 (1.08 to 1.09)	<0.001	0.97 (0.95 to 0.98)	<0.001
Male	1.13 (1.09 to 1.17)	<0.001	1.01 (0.97 to 1.05)	0.76
Race
Caucasian	Referent		Referent
African American	1.21 (1.17 to 1.26)	<0.001	1.01 (0.96 to 1.05)	0.74
Other	0.84 (0.79 to 0.90)	<0.001	0.92 (0.86 to 0.98)	0.01
Payer
Medicare	Referent		Referent
Medicaid	0.74 (0.70 to 0.77)	<0.001	1.03 (0.97 to 1.09)	0.42
Other	0.57 (0.55 to 0.60)	<0.001	0.86 (0.82 to 0.91)	<0.001
Hospital service
Medicine	Referent		Referent
Gynecologyobstetrics	0.18 (0.16 to 0.20)	<0.001	0.50 (0.45 to 0.56)	<0.001
Neurosciences	0.43 (0.40 to 0.46)	<0.001	0.76 (0.70 to 0.82)	<0.001
Oncology	1.14 (1.07 to 1.22)	<0.001	1.18 (1.10 to 1.28)	<0.001
Pediatrics	0.54 (0.51 to 0.57)	<0.001	0.77 (0.71 to 0.83)	<0.001
Surgical sciences	0.57 (0.54 to 0.60)	<0.001	0.92 (0.87 to 0.97)	0.002
Discharge location
Home			Referent
Facility (SNF, rehabilitation facility)	1.90 (1.77 to 2.03)	<0.001	1.11 (1.02 to 1.19)	0.009
Home with homecare or hospice	1.73 (1.64 to 1.83)	<0.001	1.26 (1.19 to 1.34)	<0.001
Other	1.89 (1.78 to 2.00)	<0.001	1.25 (1.18 to 1.34)	<0.001
Length of stay, d	1.03 (1.02 to 1.03)	<0.001	1.00 (1.00 to 1.01)	<0.001
APRDRG‐SOI expected readmission rate, %	1.08 (1.07 to 1.08)	<0.001	1.06 (1.06 to 1.06)	<0.001
AHRQ Comorbidity Index (1 point)	1.27 (1.26 to 1.28)	<0.001	1.11 (1.09 to 1.12)	<0.001
Discharge summary completed >3 days	1.09 (1.04 to 1.14)	<0.001	1.09 (1.05 to 1.14)	<0.001

Figure 1

DISCUSSION

In this single‐center retrospective analysis, the number of days to complete the discharge summary was significantly associated with readmissions after hospitalization. This association was independent of age, gender, comorbidity index, payer, discharge location, length of hospital stay, expected readmission rate based on diagnosis and severity of illness, and all hospital services. The odds of readmission for patients with delayed discharge summaries was small but significant. This is important in the current landscape of readmissions, particularly for institutions who are challenged to reduce readmission rates, and a small relative difference in readmissions may be the difference between getting penalized or not. In the context of prior studies, the results highlight the role of timely discharge summary as an under‐recognized metric, which may be a valid litmus test for care coordination. The findings also emphasize the potential of early summaries to expedite communication and to help facilitate quality of patient care. Hence, the study results extend the literature examining the relationship of delay in discharge summary with unfavorable patient outcomes.[15, 32]

In contrast to prior reports with limited focus on same‐hospital readmissions,[18, 33, 34, 35] readmissions beyond 30 days,[12] or focused on a specific patient population,[13, 36] this study evaluates both intra‐ and interhospital 30‐day readmissions in Maryland in an all‐payer, multi‐institution, diverse patient population. Additionally, prior research is conflicting with respect to whether timely discharges summaries are significantly associated with increased hospital readmissions.[12, 13, 14, 15] Although it is not surprising that inadequate care during hospitalization could result in readmissions, the role of discharge summaries remain underappreciated. Having a timely discharge summary may not always prevent readmissions, but our study showed that 43% of readmission occurred before the discharge summary completion. Not having a completed discharge summary at the time of readmission may have been a driver for the positive association between timely completion and 30‐day readmission we observed. This study highlights that delay in the discharge summary could be a marker of poor transitions of care, because suboptimal dissemination of critical information to care providers may result in discontinuity of patient care posthospitalization.

A plausible mechanism of the association between discharge summary delays and readmissions could be the provision of collateral information, which may potentially alter the threshold for readmissions. For example, in the emergency room/emergency department (ER/ED) setting, discharge summaries may help with preventable readmissions. For patients who present repeatedly with the same complaint, timely summaries to ER/ED providers may help reframe the patient complaints, such as patient has concern X, which was previously identified to be related to diagnosis Y. As others have shown, the content of discharge summaries, format, and accessibility (electronic vs paper chart), as well as timely distribution of summaries, are key factors that impact quality outcomes.[2, 12, 15, 37, 38] By detailing prior hospital information (ie, discharge medications, prior presentations, tests completed), summaries could help prevent errors in medication dosing, reduce unnecessary testing, and help facilitate admission triage. Summaries may have information regarding a new diagnosis such as the results of an endoscopic evaluation that revealed the source of occult gastrointestinal bleeding, which could help contextualize a complaint of repeat melena and redirect goals of care. Discussions of goals of care in the discharge summary may guide primary providers in continued care management plans.

Our study findings underscore a positive correlation between late discharge summaries and readmissions. However, the extent that this is a causal relationship is unclear; the association of delay in days to complete the discharge summary with readmission may be an epiphenomenon related to processes related to quality of clinical care. For example, delays in discharge summary completion could be a marker of other system issues, such as a stressed work environment. It is possible that providers who fail to complete timely discharge summaries may also fail to do other important functions related to transitions of care and care coordination. However, even if this is so, timely discharge summaries could become a focal point for discussion for optimization of care transitions. A discharge summary could be delayed because the patient has already been readmitted before the summary was distributed, thus making that original summary less relevant. Delays could also be a reflection of the data complexity for patients with longer hospital stays. This is supported by the small but significant relationship between LOS and days to complete the discharge summary in this study. Lastly, delays in discharge summary completion may also be a proxy of provider communication and can reflect the culture of communication at the institution.

Although unplanned hospital readmission is an important outcome, many readmissions may be related to other factors such as disease progression, rather than late summaries or the lack of postdischarge communication. For instance, prior reports did not find any association between the PCP seeing the discharge summaries or direct communications with the PCP and 30‐day clinical outcomes for readmission and death.[26, 39] However, these studies were limited in their use of self‐reported handoffs, did not measure quality of information transfer, and failed to capture a broader audience beyond the PCP, such as ED physicians or specialists.

Our results suggest that the relationship between days to complete discharge summaries and 30‐day readmissions may vary depending on whether the hospitalization is primarily surgical/procedural versus medical treatment. A recent study found that most readmissions after surgery were associated with new complications related to the procedure and not exacerbation of prior index hospitalization complications.[40] Hence, treatment for common causes of hospital readmissions after surgical or gynecological procedures, such as wound infections, acute anemia, ileus, or dehydration, may not necessarily require a completed discharge summary for appropriate management. However, we caution extending this finding to clinical practice before further studies are conducted on specific procedures and in different clinical settings.

Results from this study also support institutional policies that specify the need for practitioners to complete discharge summaries contemporaneously, such as at the time of discharge or within a couple of days. Unlike other forms of communication that are optional, discharge summaries are required, so we recommend that practitioners be held accountable for short turnaround times. For example, providers could be graded and rated on timely completions of discharge summaries, among other performance variables. Anecdotally at our institutions, we have heard from practitioners that it takes less time to complete them when you do them on the day of discharge, because the hospitalization course is fresher in their mind and they have to wade through less information in the medical record to complete an accurate discharge summary. To this point, a barrier to on‐time completion is that providers may have misconceptions about what is really vital information to convey to the next provider. In agreement with past research and in the era of the electronic medical record system, we recommend that the discharge summary should be a quick synthesis of key findings that incorporates only the important elements, such as why the patient was hospitalized, what were key findings and key responses to therapy, what is pending at the time of discharge, what medications the patient is currently taking, and what are the follow‐up plans, rather than a lengthy expose of all the findings.[13, 36, 41, 42]

Lastly, our study results should be taken in the context of its limitations. As a single‐center study, findings may lack generalizability. In particular, the results may not generalize to hospitals that lack access to statewide reporting. We were also not able to assess readmission for patients who may have been readmitted to a hospital outside of Maryland. Although we adjusted for pertinent variables such as age, gender, healthcare payer, hospital service, comorbidity index, discharge location, LOS, and expected readmission rates, there may be other relevant confounders that we failed to capture or measure optimally. Median days to complete the discharge summary in this study was 8 days, which is longer than practices at other institutions, and may also limit this study's generalizability.[15, 36, 42] However, prior research supports our findings,[15] and a systematic review found that only 29% and 52% of discharge summaries were completed by 2 weeks and 4 weeks, respectively.[9] Finally, as noted above and perhaps most important, it is possible that discharge summary turnaround time does not in itself causally impact readmissions, but rather reflects an underlying commitment of the inpatient team to effectively coordinate care following hospital discharge.

CONCLUSION

In sum, this study delineates an underappreciated but important relationship of timely discharge summary completion and readmission outcomes. The discharge summary may be a relevant metric reflecting quality of patient care. Healthcare providers may begin to target timely discharge summaries as a potential focal point of quality‐improvement projects with the goal to facilitate better patient outcomes.