Elderly at risk in care transitions When discharge summaries are poorly transferred and used –a descriptive study

In Sweden, separate hospital and primary care medical records and thus separate medication lists are common. Hence, adequate information transfer in care transitions is important but is often insufficient [1–3], which increases the risk of medication errors [4].

Elderly people are at particular risk of re-admission and adverse outcomes after hospital discharge [5, 6]. Polypharmacy is common among the elderly [7, 8]. The risk of adverse drug reactions consequently increases [8, 9], which along with medication errors contributes to increased illnesses and high health care costs [10]. However, many adverse drug reactions are preventable according to both Swedish and American studies [8, 9, 11, 12]. Medication reconciliation and discharge summaries with medication reports reduce medication errors and health care consumption [7, 13–15]. Well-functioning routines for medical information transfer and follow-up are also essential in care transitions [7, 8], especially for the elderly where interventions to improve care transitions seem beneficial [16]. Furthermore, adequate follow-up in primary care requires correct discharge information [1]. The discharge summary must also fulfil the requirements of the general practitioners (GPs). In some previous European studies, the GPs primarily wanted immediately given and accurate information on drug changes [1, 17].

The advantages of discharge summaries with medication reports are well-known [15, 16], but the transfer of such summaries to primary care has been less explored. If the discharge summary is not properly transferred to and used in primary care, then the benefits may be lost. Increased knowledge of transfer and use of information may help improve care transitions, particularly for elderly patients who are at high risk of medication errors and adverse drug reactions.

The aim of this study was to assess the transfer of discharge summaries with medication reports from hospital to primary care both directly and through exploring primary care experiences, as well as the use of the information, i.e. the updating of medication lists in primary care electronic medical records after drug changes and making a patient chart entry regarding medication or its follow-up.

Discharge summaries from 115 patients were included (Fig. 1). The average age for all patients was 85.5 years: 86.4 years for women and 84.6 years for men. A total of 61% of the patients (70/115) were women.

Less than half of the discharge summaries for elderly patients with many drugs were received, although they are meant to inform the patient as well as the next caregiver about drug changes made during hospital admissions. In the survey, more than one-third reported the discharge summary was never/seldom received, regardless of the time span. Furthermore, almost two-thirds in the survey indicated that they always/often updated medication list/made patient chart entries upon receipt of the discharge information. However, the medical record investigation showed that after drug changes, only one third of medication lists were updated in primary care medical records after two weeks. Patient chart entries regarding medication or its follow-up were only seen in primary care medical records in every other case.

The average age of patients in this study was 86 years old and used five or more drugs. People of this age are vulnerable and often use many drugs [7, 8], with an accordingly high risk of adverse drug reactions and hospitalisation [9, 11]. Drug-related problems are common after hospital discharge [23], and drug-related readmissions are frequent [24]. A discharge summary with a medication report improves medication use [13, 14, 16, 23]. However, to fully exploit its potential the discharge summary must be adequately transferred and received, which was seen in only about 40% of cases in this study. Poor communication and information transfer in care transitions and being perceived negatively by the GPs and contributing to medication errors have also been shown previously [25–28]. In a Swedish National board of health and welfare survey [7], only around half of the primary care units received information on medication initiated during hospitalisation, more commonly through medical case histories than medication reports [7]. Information transfer often took at least a week, sometimes even more than two weeks [7]. As expected, this study had a larger proportion of transfers since inclusion was actual discharge summaries. Nevertheless, the transfer of discharge summaries was still inadequate. Furthermore, the discharge summary should also be immediately transferred to the next caregiver. Thus, although a prolonged time period might have allowed for a greater number of discharge summaries being found, we consider this less likely. Although some studies show no difference in GPs satisfaction with electronic discharge summaries [29], others clearly demonstrate improved satisfaction regarding both quality and timeliness [30–32]. Even electronically produced discharge summaries may still be manually transferred. As in our study, the electronic discharge summaries in the study by Alderton and Callen were printed and mailed to the GP [32]. However, electronic transfer was called for, deemed desirable if doable [32]. While electronic preparation may result in improved discharge summaries, it still relies on the information derived from the electronic medical records being adequate. However, increased electronic management may help improve information transfer in care transitions. A secure way of transferring the discharge summaries electronically may prevent delays in their delivery to primary care. An electronic system may also enable security check-points such as automated reminders to hospital physicians to write and send the discharge summary, as well as compulsory receipts from primary care upon receiving the discharge summaries.

In this study, medication lists were not satisfyingly updated after drug changes, although the survey respondents reported updating more frequently. Similar to our results, a recent study from the Netherlands showed one third of in-hospital prescription changes was not or incorrectly documented in the primary care medical record [33], which is in line with a previous study on post-discharge medication-related information [34]. According to previous Swedish and American studies, discrepancies between the patients’ intended medication regimen and the medication list in primary care are common [35–37], even with a common medical record [35, 36], and the need for great improvement regarding updated medication lists was noted [38]. An accurate medication list is essential to assess the patient’s symptoms as well as the risks and effects of treatment [28]. Failure to update the medication list could possibly result in medication errors. A large share of medication errors is potentially harmful [39, 40] and may lead to preventable adverse drug events [41]. A poorly updated medication list might also partly result from the well-known occurrence of medication errors in discharge summaries [42] and a lack of important drug-related information [26, 34, 43]. Although many survey respondents viewed the medication report as reliable and clear and the discharge summary of great help for medication follow-up, many had experienced lack of reason for drug changes in the medication report thus possibly affecting the GPs’ attitude towards updating the medication list. Piecing the information together is also very time consuming. The type of drug that was changed may also affect the update, since drugs may be viewed as being of different importance. However, although not examined in our study, a previous study of discrepancies in the medication list noted cardiovascular drugs as those that are most commonly affected [35], which are likely often of importance. Regardless, updating the medication list is an essential responsibility for any physician [44].

Making a patient chart entry and updating the medication list might be considered unnecessary; since the discharge summary is scanned into the primary care medical records. However, this means uncertainty concerning which list that is correct. Since clear routines are lacking it is likely up to the individual doctor if and when a patient chart entry is made, which is a national problem [7].

Routines for content and transfer of discharge summaries may reduce care transition medication errors [7, 28]. Primary care confirmation of the information transfer before taking over responsibility for the patient has been suggested [45]. No current common routine on transfer and use of the discharge summaries exists in primary care in Sweden, merely general and guiding principles regarding medication management [46] as in some other countries [47, 48]. Although many of the survey respondents had discussed the topic, few had written a local routine. This may affect its use, i.e. updating the medication list and planning any follow-up.

Further, almost 30% reported never/seldom following up drug changes even if needed, which risks delayed detection of side-effects and other drug-related problems. The reasons behind abstaining from follow-up are not known. However, in the survey free text comments, the need for a formal referral for follow-up as well as lack of time to use the discharge summary was noted. Noting but not actively following up drug changes as well as insufficient time to update medication lists implies a risk of medication errors and drug-related problems. Targeting this may increase medication safety and reduce costs. The possibility of errors on admission was also highlighted. Keeping primary care medication lists accurate counteracts this. A common medication list for hospital and primary care was also proposed in the survey free text comments. Even though a common list could increase medication safety, this may fail due to unsatisfactory maintenance and frequent errors [35, 38]. In addition, hoping for a future common list does not eliminate the responsibility to keep current medication lists accurate. An inaccurate list is unreliable and unusable as well as potentially risky for the patient.

The strengths of this study are the two perspectives on studying information transfer, where the medical records review was complemented by the survey. Moreover, this study has a primary care focus on information transfer; an area that is not well explored in Sweden.

A possible limitation of this study may be the timeframe; the time period of two weeks may have contributed to the low share of updated medication lists and patient chart entries in the primary care medical records. However, despite possible delayed medical secretary writing and physicians’ heavy work burden, follow-up of these fragile patients should be initiated within this timeframe [8, 9]. Still, it is possible some GPs update the medication list at a later point in time, for example the patient’s next visit, which may affect medical safety. Furthermore, opinions of survey non-respondents (44 primary care units) are not known. It was advised to answer the survey in consultation with the chief physician. Hence, opinions of a single GP may be represented rather than those of all colleagues. As previously noted, GPs are often individualists that work in their own way, without the management leading the medical work [38]. It is possible the non-respondents would report updating medication lists and making patient chart entries to a lower extent. However, the survey was not primarily sent to the physicians but the head of the primary care unit. Further, the survey examined their views of their actions, while the first part of the study examined the actual share of updated medication lists and included all primary care units receiving discharge summaries during the study period, regardless of whether they later answered the survey or not. Nevertheless, web surveys are commonly associated with low response rates, especially physician surveys [49], hence the response rate in our study is acceptable. Further, the survey reflected all discharge summaries while the review of the primary care medical records focused on elderly patients with many drugs. However, differing views on information transfer due to patient type was not expected.

Information transfer was insufficient when elderly patients were discharged from hospital to primary care. Many discharge summaries were lost, an unsatisfactory proportion of medication lists were updated and patient chart entries were not always seen, although stated being done more often than was actually noted. Even though discharge summaries were considered clear and reliable, important drug-related information was often noted as missing. The shortcomings noted in this study imply a risk of medication errors and drug-related problems in care transitions.