Background: Populations in many high-income countries are ageing, with an ever-increasing proportion of the population aged 65 years or older. Despite increasingly better health in older people, susceptibility to chronic illness increase with age. As life expectancy increases, the length of time people can live with chronic illness increases correspondingly, mainly due to improved medication treatments. Decreased number of hospital beds per capita and length of stay in hospital has gained primary care an increasing role in the healthcare system, with higher demands on patients and their knowledge and abilities to manage medications and self-management.

Aim: The overarching aim of this thesis was to explore how medication regimens are communicated in primary care consultations and in written discharge letters.

Methods: In Study I, passive participant observations of primary care consultations were audio-recorded, transcribed and analysed using content analysis. Study II had a convergent mixed methods design. An assessment matrix, constructed based on previous research, was used to assess and quantify discharge letter content. The quantified discharge letter content, questionnaires and register data were used to calculate correlations between discharge letter content and readmission rate as well as self-rated quality of care transition. Finally, associations between discharge letter content and time to readmission were calculated both univariable and multivariable. In addition to discharge letter content, several other potential independent variables were included in the multivariable analysis.

Results: Both studies show that physicians were prone to give information about medications and blood-samples or other examinations performed in advance to the consultation (Study I) or during the hospital admission (Study II). The physicians were, however, less prone to inform patients about self-management and lifestyle changes, symptoms to be aware of, and what to do in case they would appear. Communication was occasionally hindered by misunderstandings, e.g., when vague expressions or words with ambiguous meaning was used. Ambiguities e.g., arose due to dialectal disparity. Although physicians mainly communicated in plain language with patients, medication names imposed a significant problem for patients and in communication about medications. Discharge letter content was not associated to readmissions, the only significant predictor variables for time to readmission were previous admission the past 180 days and birth outside the Nordic countries. Discharge letters with more content were, on the other hand, correlated to worse self-estimated quality of care transition from hospital to home (Study II).

Conclusions: Physicians informed patients about tests and examinations performed in the past time, and comprehensive information was provided about medications, both during consultations and in discharge letters. However, information about symptoms to be aware of and measures to take in case they would appear was scarce in consultations and discharge letters. In conversations where lifestyle changes were raised, the topic was quickly dropped without recommendations or offering support if the patient showed unconcern. Lifestyle changes in relation to chronic illness and medications were rarely discussed. Improved lifestyle as a means of reducing the need for medications was not discussed or informed about in discharge letters. Discharge letter content did not have any impact on readmissions.

Background

Care transitions are high-risk processes, especially for people with complex or chronic illness. Discharge letters are an opportunity to provide written information to improve patients' self-management after discharge. The aim of this study is to determine the impact of discharge letter content on unplanned hospital readmissions and self-rated quality of care transitions among patients 60 years of age or older with chronic illness.

Methods

The study had a convergent mixed methods design. Patients with chronic obstructive pulmonary disease or congestive heart failure were recruited from two hospitals in Region Stockholm if they were living at home and Swedish-speaking. Patients with dementia or cognitive impairment, or a "do not resuscitate" statement in their medical record were excluded. Discharge letters from 136 patients recruited to a randomised controlled trial were coded using an assessment matrix and deductive content analysis. The assessment matrix was based on a literature review performed to identify key elements in discharge letters that facilitate a safe care transition to home. The coded key elements were transformed into a quantitative variable of "SAFE-D score". Bivariate correlations between SAFE-D score and quality of care transition as well as unplanned readmissions within 30 and 90 days were calculated. Lastly, a multivariable Cox proportional hazards model was used to investigate associations between SAFE-D score and time to readmission.

Results

All discharge letters contained at least five of eleven key elements. In less than two per cent of the discharge letters, all eleven key elements were present. Neither SAFE-D score, nor single key elements correlated with 30-day or 90-day readmission rate. SAFE-D score was not associated with time to readmission when adjusted for a range of patient characteristics and self-rated quality of care transitions.

Conclusions

While written summaries play a role, they may not be sufficient on their own to ensure safe care transitions and effective self-care management post-discharge.

Trial registration

Clinical Trials. giv, NCT02823795, 01/09/2016.

Aim: To determine the impact of discharge letter content on unplanned hospital readmissions within 30 and 90 days, and to identify correlations between discharge letter content and quality of care transitions among patients with chronic illness.

Design: A convergent mixed methods design.

Methods: Discharge letters from 154 patients recruited to a randomised controlled trial were coded using an assessment matrix and deductive content analysis. The assessment matrix was based on a literature review performed to identify key elements in discharge letters that facilitate a safe care transition to home. The coded key elements were transformed into a quantitative variable of 'discharge letter score'. Bivariate correlations between discharge letter score and quality of care transition as well as unplanned readmissions within 30 and 90 days were calculated. Lastly, a multivariable Cox proportional hazards model was used to investigate associations between discharge letter score and time to readmission.

Results: All discharge letters contained at least five of eleven key elements. In less than four percent, all eleven key elements were present. Neither discharge letter score nor single key elements correlated with 30-day or 90-day readmission rate. Discharge letter score was not associated with time to readmission when adjusted for a range of patient characteristics and self-rated quality of care transitions.

Conclusion: Discharge letter score is not correlated with either 30-day or 90-day readmission rate or with time to readmission at 90 days, when patient characteristics are adjusted for.

Implications for the profession and patient care: Written discharge summaries are not enough to facilitate safe care transitions and self-management after discharge. A person-centred approach, providing written and verbal information to patients, encouraging patient involvement soon after discharge, may be needed to avoid readmission.

Objective To explore communication about medication management during annual consultations in primary care. Design: passive participant observations of primary care consultations.

Setting Two primary care centres in southern Sweden.

Participants Consultations between 18 patients (over the age of 60 years) with chronic diseases and 10 general practitioners (GPs) were observed, audio-recorded, transcribed and analysed using content analysis.

Results Four categories emerged: communication barriers, striving for a shared understanding of medication management, evaluation of the current medication treatment and the plan ahead and behavioural changes in relation to medication management. Misunderstandings in communication, failure to report changes in the medication treatment and use of generic substitutes complicated mutual understanding and agreement on continued treatment. The need for behavioural changes to reduce the need for medication treatment was recognised but should be explored further.

Conclusion Several pitfalls, including miscommunication and inaccurate medication lists, for safe medication management were identified. The purpose of annual consultations should be clarified, individual treatment plans could be used more actively during primary care consultations and efforts are needed to improve verbal communication and information continuity.No data are available.