Physician-physician communication: what's the hang-up?

Inadequate communication as patients transition across venues of care carries substantial risks. At the time of discharge, changes in medications may be missed, abnormal or pending test results ignored, and evolving aspects of the patient’s condition may not receive appropriate attention. The essential nature of timely communication at discharge has been recognized by the Joint Commission (TJC), which mandates that discharge summaries be completed within 30 days of discharge and specifies the core elements that need to be included. Though the discharge summary is a key component of the transfer of information, inadequate communication at admission carries additional hazards. At the time of admission, inaccurate medication reconciliation may occur, key elements of the history missed, prior studies unnecessarily repeated, and important aspects of the home situation overlooked. Given the importance, it could be assumed that communication with the primary care physician (PCP) is a routine staple of hospitalization and performed in a systematic manner along with other essential items, such as assessment of allergies and documentation of prior laboratory results. On the contrary, the inconsistent nature of physician–physician communication is well-established. A systematic review of the literature found that direct communication between inpatient physicians and PCPs occurred during only 3–20% of hospitalization. Deficiencies noted have included poor quality of referral letters from general practitioners to inpatient physicians in Norway; poor timeliness and quality of discharge summaries in Canada, England, and Australia; and discontinuity in the care plan after discharge at an academic hospital in the U.S.. These studies suggest that inadequate communication between inpatient and outpatient physicians is the norm rather than the exception. Two studies in this issue of JGIM offer further insights into the nature of doctor-doctor communication in the inpatient arena. Bell and colleagues surveyed 1,772 PCPs for 1,078 hospitalized patients at six academic medical centers. Of the 77% of PCPs who were aware that their patient was admitted, only 23% received direct communication from an inpatient physician at any point during hospitalization. Roy and colleagues examined communicationpatterns for readmittedpatients at two academicmedical centers to determine if the admitting team had contacted the prior inpatient team. The results are consistent with other assessments of communication: only 43.7% of admitting teams had communicated with the prior inpatient teams. Though the consequences of inadequate communication have been repeatedly demonstrated, the gains from enhanced communication have not been as clearly proven. The lack of definitive data may be due to inability to control for important confounders, inadequate power, inability to assess the quality of the communication, or intrinsic difficulties with communication preventing meaningful improvement in outcomes. In addition, most studies have examined the transfer of information at the end of hospitalization, and little examination has been done on communication at the time of admission. Benefit was shown in a randomized trial which found that an intervention to facilitate the transition from hospital to home, including a comprehensive discharge form completed by a discharge planning nurse and electronically transmitted to a nurse at the PCP’s office, markedly decreased the number of incomplete workups, though ED visits and readmissions were unchanged. A large retrospective chart review found a trend towards decreased readmission (RR 0.74) for patients for whom a discharge summary was available at the time of their follow-up visit with their PCP. Coleman and colleagues randomized 750 adults to usual care or to an intervention including a “transitions coach” and a patient-centered record designed to facilitate transfer of information across sites. This comprehensive approach to enhancing communication achieved significant reductions in rehospitalization rates at 30 days (8.3 vs. 11.9 days) and was net cost-saving. Additional support comes from a study of the impact of discharge summaries in London, which noted that 24% of patients had management affected by delayed or poor discharge summaries as determined by their PCP. In the study by Bell and colleagues in this issue, there was no significant association between the PCP having communicated with the inpatient team with the composite endpoint of death, readmission, or emergency department visits, though a nonsignificant 5% decrease in the composite outcome was noted. Though this result could have been due to chance, the study was underpowered to find a small benefit. Given the likely scale of any potential gain, future studies will need to have sufficient power to detect modest improvements in outcomes. Also, though the authors adjusted for comorbidities, this study and others may be confounded by communication being more Published online January 27, 2009