Discharge ed, doctor harassment, and more

Research summaries from ACP Hospitalist Weekly

More than a third of residents unsure who's responsible for patient education at discharge

Many residents didn't know who is primarily responsible for providing patient education at discharge, a survey study found.

Researchers emailed the survey to internal medicine residents at seven academic centers between March and May 2019 to assess who they perceive to be primarily responsible for discharge education, how these perceptions affect their own communication with patients, and how they envision improving multidisciplinary communication around discharges. The survey also asked how frequently they engaged in six discharge communication practices: explaining the purpose of medication changes, discussing red flags, explaining the purpose of follow-up appointments, outlining symptom expectations, discussing self-management of disease, and asking the patient to teach back the discharge plan. Results were published online Feb. 2 by the Journal of General Internal Medicine.

Of 966 residents invited to participate, 613 (63%) responded. The most common response (35%) was that residents were not sure who was primarily responsible for patient education at discharge, followed by the intern (27%), the resident (17%), the nurse (16%), and the attending (4%). About half (45%) pointed to the senior resident as best suited to be primarily responsible for discharge education. Of the discharge communication practices, 71% reported frequently addressing the purpose of medication changes, 69% said they discussed red flags, 52% reported explaining the purpose of follow-up appointments, 47% said they outlined symptom expectations, 39% said they discussed self-management of disease, and 17% said they ask patients to teach back the discharge plan. Compared to residents who were not sure who was responsible for discharge education, those who believed it was either the intern's or the resident's primary responsibility had 4.28 (95% CI, 2.51 to 7.30) and 3.01 (95% CI, 1.66 to 5.71) times the odds, respectively, of reporting frequent use of discharge communication practices.

When invited to provide open-ended comments on improving multidisciplinary discharge communication, residents called for team members to clarify roles and responsibilities for communicating with patients, to set expectations for communication among team members, and to redefine the culture around discharges. With regard to this last point, residents suggested a need to change the environment that shapes the transition to outpatient care. As one resident wrote, “Unfortunately, multidisciplinary rounds have become quite stressful for residents. I believe this comes from such a push to get patients out earlier and earlier.”

Among other limitations, resident responses were self-reported and thus subject to social desirability bias, the study authors noted. They added that there was a lack of input from other interdisciplinary team members or patients involved in the discharge process.

“Developing proficiency in team collaboration to discharge patients effectively and safely is a critical skill in hospital medicine,” the authors concluded. “This study demonstrates that normative beliefs of discharge education responsibility may influence reported discharge communication practices.”

Discrimination and sexual harassment commonly affect female academic hospitalists, survey finds

Gender-based discrimination and sexual harassment were commonly reported by female academic hospitalists in a recent study.

Researchers surveyed internal medicine hospitalists at 18 university-based academic institutions in the U.S. from January through June 2019. Survey questions assessed their experiences regarding gender-based discrimination and sexual harassment in their interactions with both patients and other clinicians. Results were published online Jan. 20 by the Journal of Hospital Medicine and appeared in the February issue.

Image by Getty Images
Image by Getty Images

Overall, 336 individuals (56.7% women) responded to the survey. Female hospitalists more frequently reported sexual harassment (e.g., inappropriate touching or gestures, sexual remarks, and suggestive looks) by patients compared with their male peers, both over their careers and in the last 30 days (P<0.001 for both). Compared to men, women more frequently reported being referred to with inappropriate terms of endearment (e.g., “dear,” “honey,” “sweetheart”) by patients, both over their careers and in the last 30 days (P<0.001 for both). Almost 100% of women reported being mistaken by patients for nonphysician clinicians over their careers, compared with 29% of men, and in the last 30 days, these figures were 76% and 10%, respectively (P<0.001 for both). Women also more frequently reported sexual harassment over their careers (P<0.05) and rated their sense of respect, both by patients and colleagues, lower than men did (P<0.001 for all). Finally, more women than men reported that gender negatively impacted their career opportunities (P<0.001).

Since the survey was limited to academic medical centers, these results may not reflect experiences in community or private practice settings, the authors noted. They added that the small number of participants limited their ability to perform subgroup analyses by age, race, or years in practice and that it is unknown how many physicians received the survey; therefore, they could not calculate a response rate.

“This survey shows that gender-based discrimination and sexual harassment in the academic hospitalist healthcare environment are common and more frequently experienced by female physicians, both in interactions with patients and colleagues,” the authors concluded. “Our study highlights the need to address this prevalent issue among academic hospitalists.”

Study finds wide variation in ED physicians' hospital admission rates for Medicare patients

There is substantial variation in rates of hospital admissions of Medicare patients among ED physicians at the same hospital that is unrelated to observable patient characteristics, a study found.

Researchers used Medicare fee-for-service claims for a 20% random sample of beneficiaries from Jan. 1, 2012, through Sept. 30, 2015 (when ICD-10 was introduced). They included visits to nonfederal hospital EDs in all 50 states and Washington, D.C., for beneficiaries of any age who were continuously enrolled in Medicare Parts A and B and didn't have end-stage renal disease. The sample was limited to visits for medical (non-surgical) issues, and researchers included the 37 most frequently seen diagnoses. For each visit, they determined whether the patient was discharged from the ED, admitted to the hospital, or admitted to observation status. All transfers to another hospital and visits under observation status (whether in the ED or hospital unit) were considered to be clinically equivalent to an admission. The researchers examined physician-level variation in admission rates using a mixed-effect linear regression model predicting each patient demographic and clinical characteristic as a function of physician random effects and hospital fixed effects. In addition, they examined consistency in physicians' admission rates across clinical conditions. Results were published in the February Health Affairs.

The study sample included 5,778,218 visits with 45,491 physicians at 3,480 EDs. The mean patient age at the time of ED visit was 72.5 years, and patients were predominantly women (58.4%) and White (76.7%). Emergency medicine physicians handled 81.2% of visits, compared with 12.4% for family/internal medicine clinicians and 6.5% for physicians of other specialties. The majority of physicians were men (75.3%). Admission rates varied by diagnosis, from a high of 94.9% for septicemia to a low of 8.3% for “other back problems.” The mean rate of admissions among physicians was 38.9%, but adjusted admission rates varied substantially within hospitals, ranging from 32.2% to 45.6% for physicians at the 10th and 90th percentiles, respectively, of the distribution predicted by the estimated physician-level variance (absolute difference, 13.4 percentage points; 95% CI, 13.31 to 13.44 percentage points).

Across clinical conditions, there was moderate to high correlation in admission rates at the physician level, ranging in magnitude from 0.59 to 0.96 (for example, the correlation between admission tendency was 0.73 for gastrointestinal vs. cardiovascular conditions and 0.81 for pulmonary vs. gastrointestinal conditions), meaning that physicians generally had consistently higher or lower tendencies to admit (relative to other physicians in the same hospital) across conditions. Their rates of admissions for one particular clinical condition were also predictive of their admission rates for other conditions, “suggesting that variation in admission rates reflects physician-level tendencies that are consistent across different types of clinical conditions,” the authors wrote.

Among other limitations, the study could not determine whether the variation in admission rates was associated with differences in patient outcomes, the authors noted. They added that they were unable to ascertain all potentially relevant predictors of admission (e.g., vital signs, presenting symptoms, availability of home support) from administrative claims data.

“The wide variation in ED physicians' admission rates seen in our study suggests that physician decision making contributes considerably to whether a patient in the ED is admitted and might therefore be a fruitful target for interventions” to reduce unnecessary admissions while ensuring patients who could benefit from hospitalization are admitted, the authors concluded.

Home telemonitoring may reduce readmissions in high-risk patients

Thirty days of home telemonitoring after hospital discharge may improve outcomes in patients at high risk for readmission, a recent trial found.

Researchers performed a randomized controlled trial comparing 30-day readmission and mortality rates in high-risk patients who received home telemonitoring versus standard care. Included patients had been recently discharged from two tertiary care hospitals in the Mayo Clinic system in Arizona and Florida. All patients received standard care, which included teach-back education, medication reconciliation, and a follow-up phone call from a trained nurse within 72 hours of discharge. Patients assigned to the intervention group also received home equipment to measure blood pressure, heart rate, and pulse oximetry, as well as weight in those with heart failure and glucose levels in those with diabetes. A nurse reviewed the data, which were transmitted daily. The results of the trial were published Jan. 27 by the Journal of General Internal Medicine.

Overall, 1,380 patients were randomly assigned to a treatment group, 690 to telemonitoring and 690 to standard care. Mean age was 66 years, and 52.3% were men. One hundred twelve patients in the control group and 213 in the telemonitoring group were lost to follow-up and did not complete the entire study. In a modified intention-to-treat analysis, the risk for death or readmission within 30 days was 23.7% (137 of 578 patients) in the control group versus 18.2% (87 of 477 patients) in the telemonitoring group (absolute risk difference, −5.5% [95% CI, −10.4% to −0.6%]; relative risk, 0.77 [95% CI, 0.61 to 0.98]; P=0.03). Percentages of patients with ED visits within 30 days after discharge were 14.2% in the control group (81 of 570 patients) and 8.6% (40 of 464 patients) in the telemonitoring group (absolute risk difference, −5.6% [95% CI, −9.4% to −1.8%]; relative risk, 0.61 [95% CI, 0.42 to 0.87]; P=0.005).

The researchers noted that a significant number of patients in the telemonitoring group withdrew from the study after discharge and that the study was stopped before the accrual target of 1,900 patients was reached, among other limitations. They concluded that telemonitoring for 30 days after hospital discharge in patients at high risk for readmission can help reduce readmissions and ED visits. “Telemedicine and remote monitoring are 2 technologies that have held promise in reducing the use of hospital resources and limiting readmissions of high-risk patients,” the authors wrote. “As our study targeted patients with any diagnosis who were considered high risk for readmission, the results could be applicable to a wide range of patients in other hospitals and health systems.” They called for additional studies to examine the cost-effectiveness of this intervention.