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