Original Research
Using a Structured Discharge Letter Template to Improve Communication During the Transition from a Specialized Outpatient Diabetes Clinic to a Primary Care Physician

https://doi.org/10.1016/j.jcjd.2015.06.009Get rights and content

Abstract

Objective

Transition from specialists to primary care physicians is dependent on clear communication by means of a discharge letter. Primary care physicians have indicated that letters from specialists rarely contain the details they require. As part of a quality-improvement project to improve the transition from diabetes clinics to primary care physicians, a structured discharge letter template was developed to facilitate the dictation of useful letters by specialists. The objective was to evaluate the content and quality of discharge letters created using a structured discharge letter template as compared to letters completed without the template.

Methods

Retrospective study of patients treated at the Ottawa Hospital and discharged from the outpatient diabetes clinic between November 1, 2009, and December 1, 2010. The letters were reviewed by 2 independent reviewers and were assessed for content, brevity, clarity, management plan, organization and quality. Word count, dictation and transcription times were also compared.

Results

Letters completed using the structured discharge letter template were more comprehensive and more likely to contain guidelines on management for glycemic control (51.1% vs. 14.1%; p<0.001); cardiovascular risk factors (65.61% vs. 9.8%; p<0.001); diabetes complications (79.9% vs. 5.9%; p<0.001); and provided re-referral criteria (89.3% vs. 15.7%; p<0.001). Dictation time did not differ between formats. Transcription time (20:65 min vs. 13:45 min; p<0.01) and word count (502 words vs. 292 words; p<0.001) were higher with the template.

Conclusions

The use of a structured discharge letter template improved the content and quality of discharge letters dictated by specialists. Primary care physicians were more consistently provided with valued information and given criteria for re-referral.

Résumé

Objectif

La transition des spécialistes vers les médecins de premier recours dépend de communications claires transmises par une lettre de congé. Les médecins des soins primaires ont indiqué que les lettres des spécialistes contiennent rarement les renseignements dont ils ont besoin. Dans le cadre d'un projet visant l'amélioration de la qualité pour faciliter la transition des médecins des cliniques de diabète vers les médecins de premier recours, un modèle de lettre de congé structurée était élaboré pour faciliter la dictée des lettres utiles des spécialistes. L'objectif était d'évaluer le contenu et la qualité des lettres de congé réalisées au moyen d'un modèle de lettre de congé structurée et de les comparer aux lettres réalisées sans le modèle.

Méthodes

L'étude rétrospective portait sur les patients traités à l'Hôpital d'Ottawa et ayant reçu leur congé du service de consultations externes aux patients diabétiques entre le 1er novembre 2009 et le 1er décembre 2010. Les lettres étaient revues par 2 examinateurs indépendants et étaient évaluées sur leur contenu, leur concision, leur clarté, leur plan de prise en charge, leur organisation et leur qualité. Le nombre de mots, les temps de dictée et de transcription étaient également comparés.

Résultats

Les lettres remplies au moyen du modèle de lettre de congé structurée étaient plus complètes et plus susceptibles de contenir les recommandations sur la prise en charge de la maîtrise de la glycémie (51.1% vs 14.1%; p < 0.001); les facteurs de risque cardiovasculaire (65.61% vs 9.8%; p < 0.001); les complications liées au diabète (79.9% vs 5,9%; p < 0.001); les critères à long terme et de réorientation requis (89.3% vs 15.7%; p < 0.001). Le temps de dictée ne différait pas entre les formats. Le temps de transcription (20:65 min vs 13:45 min; p < 0.01) et le nombre de mots (502 mots vs 292 mots; p < 0.001) étaient plus grands en utilisant le modèle.

Conclusions

L'utilisation d'un modèle de lettre de congé structurée améliorait le contenu et la qualité des lettres de congé dictées par les spécialistes. Les médecins de premier recours recevaient plus régulièrement des informations précieuses et les critères de réorientation requis.

Introduction

Diabetes is a chronic disease that places individuals at risk for multiple short- and long-term complications and frequently depends on multidisciplinary care by specialists and primary care physicians. The increasing prevalence and costs of type 2 diabetes has resulted in mounting pressure on both primary care physicians and diabetes specialists in Canada. Primary care physicians play a significant role in managing diabetes and related complications, but approximately 20% of patients living with diabetes receive their care from diabetes specialists (1). Access to healthcare specialists has been identified by both patients and providers as being a significant barrier to optimal healthcare management in Canada and is likely to become more challenging (2).

In order to reduce waiting times for new patients and reduce volumes within specialists' clinics, specialists must transfer patient care back to the primary care physicians effectively, once medical therapy has been optimized. Smooth transition from diabetes specialists to primary care physicians is reliant on clear, concise and timely communication. Discharge letters are an opportunity to inform primary care physicians that patient care is being transferred, to report recent results, to identify current issues, and to provide guidance for ongoing management of diabetes care. Problem lists and structured letters have been identified by primary care physicians as key features that improve communication and facilitate ongoing medical management 3, 4. Primary care physicians have indicated, additionally, that although letters from specialists often contain details about examinations and investigations, they often lack the information primary care physicians seek, including treatment plans, future management needs and expected outcomes (5).

Several studies have demonstrated the benefits of structured discharge letters and the value primary care physicians place on this type of communication. However, information is lacking in terms of how to encourage and support physicians in generating these types of letters.

The Tools for Transition (TFT) Program at the University of Ottawa was established to facilitate the transition of patients from a multidisciplinary diabetes clinic back to their primary care physicians. The program was managed by a steering committee consisting of endocrinologists, primary care physicians, advance practice nurses, dietitians and diabetes nurse specialists. The objectives of the program were as follows:

  • 1.

    To develop and implement tools to facilitate the transition of patients with type 2 diabetes from specialist care to primary care, once diabetes management is optimized.

  • 2.

    To promote ongoing diabetes management according to clinical practice guidelines after discharge.

As part of this quality-improvement project, a structured discharge letter template was developed and implemented to improve communication between endocrinologists and primary care physicians at discharge from the specialty clinic so as to facilitate smooth transitions to the primary care physicians.

The objectives of this study were to evaluate the content, quality, practicality and user satisfaction of a structured discharge letter produced by specialists based on a template, as compared to discharge letters generated without a template.

Section snippets

Patients and settings

This was a retrospective study of patients with type 2 diabetes who were treated in the outpatient specialist diabetes clinics at the Ottawa Hospital, a tertiary care centre. This diabetes centre provides multidisciplinary care by endocrinologists, diabetes nurse educators, dietitians and social work, to approximately 20 000 patients with diabetes-related visits per year. A centralized hospital service was used for transcription of notes dictated through a telephone.

Patients were included if

Results

During the assessment period, 73 discharge letters were completed by 10 different physicians and were included in this analysis. Before the implementation of the structured discharge letter template, 45 letters were completed (29 by staff endocrinologists and 16 by trainees), and 28 used the template (23 staff endocrinologists and 2 trainees). There was an equal distribution of endocrinologists who used both types of discharge letters, with the exception of 3; 1 used the template predominantly,

Discussion

Management of patients with type 2 diabetes often involves a balance between specialist care and primary care. Transferring stable and medically optimized patients can help to facilitate access to specialist care and may reduce waiting times. Transitioning patients' care from specialists' clinics to their primary care physicians can be challenging and should not impact continuity of care. Clear communication and the transmission of relevant medical information between medical specialists and

Conclusions

In summary, the transition of patient care from specialist diabetes clinics to primary care physicians may be challenging and can impact the continuity of care. The benefits of structured discharge letters have been well described in the literature. We have demonstrated that the use of a structured discharge template to generate discharge letters improves the quality and content of letters dictated by specialists, standardizes the information provided to primary care physicians, provides

Acknowledgment

The authors recognize NovoNordisk and LifeScan Canada for the unrestricted education grant that made this work possible.

References (15)

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