Australian general practitioners’ views on qualities that make effective discharge communication: a scoping review

Eligibility criteria

Primary research papers were eligible for inclusion if they discussed patients discharging from hospital to primary care with discharge communication to GPs and GPs’ perceptions of best practice discharge communication in Australia. Limits were not set on dates of publication in the inclusion criteria. The reason for this is because what GPs perceived to be effective discharge communication years and even decades ago may still be relevant today.

Articles were excluded from review if they discussed discharge summaries to nursing homes, nursing discharge summaries, pharmacist only discharge medication records and summaries and allied health discharge summaries. Systematic reviews with or without meta-analysis, guidelines and standards were excluded from review.

Although there are some similarities between Australian and other healthcare systems, there are also vast differences in referral processes in care systems, models of subsidised GP consults and hospital funding which may affect a patient’s ability to link back into their primary healthcare network. For these reasons, only Australian studies were included for specificity.

Data sources – search strategy and information sources

A search was performed in Medline via OVID, Scopus and the Cochrane register. A combination of keywords and MeSH heading search terms were used, and full search strategies are listed in Supplementary Tables S1–S3. The reference lists of identified articles were also searched for additional sources of evidence.

Endnote and Microsoft Excel software were used to manage results of the search. Out of 1674 results, 662 duplicates were removed by both automated and manual methods. Authors S.P. and M.G. screened the remaining 1012 titles, where 171 abstracts were then screened leaving 23 full text articles for review. After full text review, 20 articles met eligibility criteria and were retrieved for critical appraisal.

Critical appraisal of selected studies for inclusion

Three of the authors critically appraised the 20 full text articles independently using JBI critical appraisal tools. JBI critical appraisal tools were chosen to assess methodological quality for design bias, conduct and analysis of the selected studies in the systematic scoping review (Aromataris and Munn 2020). Of the 20 articles appraised, two did not meet critical appraisal due to being deemed poor quality studies scoring lower than 50% in the appraisal tools. All other studies were of high-quality scoring an average of 80% on applicable appraisal tools as seen in Table 1. Any inconsistent opinions on study selection were resolved by meeting and discussion.

Ethics approval

No ethics approval is required for a systematic review. This systematic scoping review protocol was registered with Open Science Framework on the 4th of October 2021.

Timeliness of receipt of discharge summaries

Five articles discussed that GPs viewed timeliness of discharge summary receipt to be a problem (Castleden et al. 1992; Karaksha et al. 2010; Stainkey et al. 2010; Rowlands et al. 2012; Brodribb et al. 2016; Mahfouz et al. 2017). One article demonstrated that GPs appeared to be satisfied with timeliness (Middleton et al. 2004). None of the articles made reference to a specific timeframe, rather they reported on whether the GPs were happy with the timeliness of discharge summary delivery at the time of undertaking the study. Jiwa et al. (2014) had GPs undertake simulated post-discharge consultations with patient videos as surrogate for recently discharged patients. It found that the GPs considered the discharge summary to be timely if it was present by the time they viewed the patient simulation video rather than if it was received after the consultation video.

Length, formatting and readability of discharge summaries

Four studies identified that GPs had preferences regarding the overall format of the discharge summary communication. There was a preference noted from one study for longer more detailed discharge letters (Jiwa et al. 2014). Conversely, four other studies commented that it was difficult to find salient information from hard to read/interpret discharge summaries (Stainkey et al. 2010; Mahfouz et al. 2017; Kilgour et al. 2019a, 2019b), and that discharge summaries contain too much irrelevant detail (Kilgour et al. 2019a). One study concluded that 46.9% of GPs were very dissatisfied/dissatisfied with the format of discharge summaries, noting them to be too time-consuming, difficult to read and difficult to extract important information (Mahfouz et al. 2017).

Clinical disciplines and diagnosis related groups

It is noted in the literature that GPs have preferences for specific information in discharge summaries for different clinical disciplines and diagnosis related groups. Most studies focused on specific details that GPs felt were of particular importance for those patient groups.

Regarding general surgical patients, GPs perceived that discharge information on opioids was inadequate and that opioid management plans were not provided. Only 26.3% of GPs stated they were satisfied with opioid-related communication (Tran et al. 2020). Within this same study it was found that roughly one quarter of summaries had at least one discrepancy between opioids listed and opioids dispensed, and almost 90% of summaries did not contain an opioid management plan (Tran et al. 2020). Specifically, in elective total knee and hip replacement surgery, GPs rated early post-operative actions required by the GP, medications prescribed in hospital, allergies noted, summary of the surgical procedure and details on surgical/post-operative management, to be essential in discharge communication (Briggs et al. 2012).

For communication surrounding intensive care unit patients, only 9% of GPs were unsatisfied or very unsatisfied with lack of information pertaining to the intensive care unit admission in the discharge summary. This study identified that GPs perceived that there was insufficient information specifically about patient rehabilitation and ongoing patient care needs (Williams et al. 2010).

In people living with dementia, Kable et al. (2015) identified themes that commented on GPs needing to revise planned discharge medications for acute behavioural disturbances. GPs commented on excessive medication prescribing in this patient group, with medications often no longer required and with the potential for harm to these patients when returning to their home environment. Kable et al. (2019) also identified that information provided about stroke survivors was inadequate regarding follow up requirements, such as cognitive and support requirements (e.g. diet consistency, communication supports, mobility) and social issues (e.g. home environment, transport, driving).

For postnatal follow up of gestational diabetes mellitus patients, Kilgour et al (2019a) identified that GPs would like to receive specific advice on gestational diabetes mellitus care, and for this information to be listed at the beginning of the discharge summary. GPs preferred less detailed information about intrapartum complications, long term management of gestational diabetes and management of future pregnancies compared with hospital clinicians. GPs preferred more detail in discharge summaries for complicated cases and less detail for less complicated cases.

Communication of medication information at hospital discharge

Six studies discussed communication of medication related information at hospital discharge. Mahfouz et al. (2017) found that 65.5% of GPs were very unsatisfied or unsatisfied with medication changes in the discharge summary. Conversely, Stainkey et al. (2010) found that 43.4% of GPs were very satisfied with medications safely allowing for ongoing management. Themes identified by three of these studies were that medication information is often missing, incomplete or inaccurate in the discharge summary and that GPs need, but rarely receive, information about medication changes (Stainkey et al. 2010; Kable et al. 2015, 2019). Two other studies reported that GPs viewed the reasons for changes of medications as essential information (Briggs et al. 2012; Mahfouz et al. 2017).

Summary of evidence

This scoping review identified 18 primary studies that investigated Australian GPs’ views on the qualities that make up effective discharge communication from hospital discharge to the community. This scoping review is the first to search and map the literature pertaining specifically to Australian GPs’ views of the qualities and preferences of discharge communication.

It is noted that themes found in this Australia specific review were similar to Clanet et al. (2015), which was an international systematic review published in 2015. Both systematic reviews found that timeliness, readability and diagnosis and treatment related information were important. The themes, and which publications discussed or referred to them, are listed in Table 3.

The findings identified that GPs prefer to receive clinical discipline and diagnosis specific information in discharge summaries (Williams et al. 2010; Briggs et al. 2012; Kable et al. 2015, 2019; Kilgour et al. 2019a; Tran et al. 2020). The wide range of detail that GPs prefer to receive for specific diagnoses, raises questions as to whether discharge summaries need to be better individualised and whether clinical coding could possibly be used to link diagnosis with diagnosis specific discharge summary templates to prompt clinicians to add pertinent information.

The range of data describing GPs’ views on timeliness of discharges summaries being received was conflicting. This ranged from GPs being satisfied with timeliness, to timeliness being listed as a problem with the handover process (Castleden et al. 1992; Middleton et al. 2004; Karaksha et al. 2010; Stainkey et al. 2010; Rowlands et al. 2012; Brodribb et al. 2016; Mahfouz et al. 2017). The findings from Jiwa et al. (2014) may explain this by way of noting that the preferred timeliness may not be specific to a fixed time frame, but rather if the discharge communication is received prior to the patient attending the GP for a post-discharge appointment. This raises questions about whether proactive planning and booking GP appointments may assist with the timeliness of discharge summary receipt, because there would be a better understanding about when the discharge summaries would need to be completed by. At the time of writing, in Australia there is no standard guidance or key performance indicator that dictates when a discharge summary or other forms of discharge communication should be completed or received by the recipient. Some individual facilities, or state-based health services, may provide guidance on this for clinicians, but it is not consistent. Implementation of standardised, evidence-based guidance of a time interval post-hospital discharge that the discharge summary is received within, could be a possible patient-safety quality improvement intervention.

It was clear in the data that medication related information in discharge summaries is of particular importance to GPs and is often incomplete or inaccurate. Time poor clinicians, and medication history not completed on admission, are some of the reasons for this. The evidence of poor communication of medication related information at hospital discharge alludes to the need for there to be more resources allocated to support improvements, for example, educational interventions, or greater pharmacist involvement in discharge communications. There is an example in the international literature of an expanded scope of prescribing pharmacists, with additional post-graduate training surrounding completing medical discharge summaries. This study showed that for discharge summaries written by these pharmacists, the discharge summary completion time, time to patient discharge and medication errors all decreased (Biggs and Biggs 2020). Australian hospital pharmacists are commonly involved with compiling medication lists as an education and communication tool for patients and community providers, however, they are not currently involved in writing discharge summaries as such.

Problems with discharge summary length, format and readability were identified in the literature (Stainkey et al. 2010; Jiwa et al. 2014; Mahfouz et al. 2017; Kilgour et al. 2019a, 2019b). In 2017, the Australian Commission on Quality in Healthcare released National Guidelines for On-Screen Presentation of Discharge Summaries, providing guidance on format, font and contents of electronic discharge summaries (Australian Commission on Safety and Quality in Health Care 2017b). Thirteen of the included studies were published prior to 2017 when this guidance was released. None of the included studies that were published after 2017 compared discharge summary format or contents to the Australian guidance.

It was noted in the literature that most of the studies did not discuss whether the discharge summaries were or were not computer generated. This is significant to the scoping review question because the method of writing/generation of a discharge summary could affect its quality. It could be implied that more recent papers discuss computer-generated discharge summaries. Computer-generated or electronic discharge summaries started becoming commonplace in the last 10–15 years. The timelines for transition to these systems varies greatly across Australia.

Eight of the 18 included studies were published more than 10 years ago, and some aspects of those studies could now be considered outdated, particularly when taking into consideration recent technology advances pertaining to integrated electronic medical records in hospitals. None of the included studies investigated discharge communication since implementation of integrated electronic medical records. The timing for the implementation of use of these programs across Australia has varied greatly across the last 10–15 years.

This scoping review found that there is a paucity of Australian studies investigating other forms of discharge communication. With technology advances, there could be other ways in which discharge information could be communicated, for example, application-based methods or telehealth-based methods. There are some examples in the international literature of using application-based and video-based methods for providing discharge communication from hospital to patients or caregivers. These include application-based discharge communication to assist stroke patients after hospital discharge (Siegel et al. 2016), provision of audio–visual discharge instructions on pain and fever management to caregivers for acute otitis media in children (Belisle et al. 2019) and provision of audio–visual discharge instructions to general medical inpatients on discharge (Newnham et al. 2015). This scoping review did not identify any novel methods of communicating discharge information from hospitals to GPs in the Australian context.

It was also noted that most of the studies included for review were conducted at single healthcare institutions in metropolitan areas in Australia. Most of the studies did not specify whether they were tertiary hospital facilities or other smaller (primary or secondary) hospital facilities. There was a lack of representation of studies conducted that included regional, rural and remote areas, which would be an area of interest for future research. A lack of large sample sizes within the studies identified was also observed (samples sizes ranged from 4 to 163 GPs). Studies with larger sample sizes would be able to provide a more robust evidence base to be able to guide recommendations and practice change relating to discharge communication. Future studies with a broader capture, for example, in multi-site studies of larger sample sizes, inclusive of rural and Aboriginal or Torres Strait Islander patient demographics, would ensure that results are better representative of the wider Australian population. Including these patient demographics in future studies would provide a better understanding of what GPs need regarding discharge communication for these specific patient groups.

Implications for research and practice

In mapping the literature pertaining to Australian GPs’ views on the qualities that make up effective discharge communication, this scoping review has identified gaps in the current evidence base.

There are opportunities for future research and practice change with the aim of improving patient outcomes, patient safety and subsequent economic benefits to health services in the following areas: