INTRODUCTION

Optimizing delivery of care at stages of transitions has been a prominent focus of healthcare reform.1 , 2 At the same time, effective care coordination and continuity is increasingly complex as our healthcare system becomes progressively more fragmented. A major systemic element of this fragmentation began in the 1990s with the introduction of hospitalists and a separation of responsibility for inpatient care from outpatient care.3 This divorce of inpatient and outpatient care has been shown to increase the challenge of care coordination.4 Prominent among care transitions is the lack of direct communication among providers across the various health care settings.5 The delay and limited transfer of information on patients’ medical histories from outpatient providers to the acute care setting can lead to omitted and/or redundant evaluations, which can result in increased length of stay and increased risk of morbidity and mortality.4 Although admission has been cited as a time of high risk for poor coordination, research to date has mainly focused on characterizing and improving the transition from the acute care setting back to the outpatient setting.6 – 10 The Transitions of Care Consensus Policy Statement noted that there has been “more extensive study” of the inpatient to outpatient transition, but that the outpatient to inpatient transition should also be a “clear priority.”11

To address this gap in evidence, we performed a systematic review of the current literature on transition of care from the outpatient to acute care setting with the following aims: to assess what is known regarding direct provider-to-provider communication at this specific transition of care; to evaluate the factors associated with occurrence of this communication; and to evaluate whether direct provider-to-provider communication affects quality of care as measured by mortality, readmissions, length of stay, patient and provider satisfaction, as compared to no communication or indirect communication.

METHODS

Search Strategy

We conducted a systematic review of the MEDLINE, CINAHL, Scopus, EMBASE, and Cochrane Library electronic databases from inception through 5–7 June 2014 for studies of direct communication between an outpatient provider (e.g., primary care provider, outpatient specialist, outpatient pharmacist, nursing home provider) and an acute care provider (e.g., emergency department provider, hospitalist, hospital pharmacist) at the time of transition from the outpatient to acute care. We generated search terms using database subject headings and keywords. Appendix A (see online) contains the search terms for MEDLINE. Duplicates were eliminated. We also conducted a manual search of the references of the included articles.

Eligibility Criteria

We included original articles evaluating direct communication between outpatient and acute care providers at the transition from the outpatient to acute care setting; reviews, commentaries, and meeting abstracts were excluded. We defined the term “acute care” to refer to the inpatient setting and the emergency department. We defined acute care providers as emergency department providers or inpatient providers. An outpatient provider was defined as any ambulatory-based or nursing home provider who referred patients to the acute care setting.

Direct communication could be unidirectional or bidirectional, the latter synchronous or asynchronous, and could be initiated by either party. Indirect information transfer, such as checking a patient’s electronic health chart, was not included, but direct provider-to-provider messaging through electronic health record or email was included. Examples of communication included a referral letter from a primary care provider (unidirectional), provider-to-provider telephone call (synchronous, bidirectional), or a referral letter from an outpatient provider received by the acute care provider, who then sent a fax to the outpatient provider for further clarification of the communication (asynchronous, bidirectional). Though interoperable electronic health records are increasingly available to assist in the sharing of patients’ healthcare information, we believe that direct provider-to-provider communication more fully fulfills the three dimensions of continuity of care (continuity in information, continuity in management, and continuity in the patient–physician relationship).12

Direct communication was compared to no communication or indirect communication between providers. Outcomes delineated a priori to be evaluated were health care utilization, length of stay, readmissions, patient satisfaction, provider satisfaction, morbidity and mortality.

We included both quantitative and qualitative studies. We excluded non-English language publications.

Article Selection

Two reviewers independently evaluated titles generated from the subject and key word searches. The title review was sensitive to avoid excluding eligible articles. Titles were included if they mentioned any handoffs or any transitions, communication between providers or discharge planning, coordination of care or organization of care. Titles were excluded if they were clearly only about the outpatient setting, clearly only about the acute care setting, or were not original articles. If one of the reviewers included the title, it was included in the next abstract review phase.

Abstracts of the included titles were reviewed independently by two reviewers, and were excluded if they met at least one of these criteria: not written in English, not about human subjects, not an original article (e.g., review, commentary, newsletter, or abstract), clearly not about transitions of care or clearly not about direct provider-to-provider communication (see Appendix B online). We did not exclude titles or abstracts that only mentioned the acute care-to-outpatient transition in the title/abstract, and reviewed the full texts of such articles to see if they did report on the outpatient-to-acute care transition.

Full texts of the included abstracts were reviewed independently by two reviewers, and were excluded if they were not an original article (e.g., review, commentary, newsletter or abstract) or did not describe direct/active communication (as defined in Eligibility Criteria) between outpatient and acute care providers (as defined in Eligibility Criteria) at the outpatient to acute care transition. The outpatient setting was defined as a home, clinic or nursing home. An outpatient provider was defined as a primary care provider including non-physician providers (nurse practitioners, physician assistants), primary specialists (cardiologist, nephrologist, psychiatrist, etc.) or outpatient pharmacists. The acute care setting was defined as either the emergency department or hospital. An acute care provider was defined as an emergency department provider (e.g., physicians, nurse practitioners), any type of inpatient physician or mid-level provider, or inpatient pharmacist. Communication was defined as direct/active provider-to-provider communication. Direct communication could be unidirectional or bidirectional, the latter synchronous or asynchronous, and could be initiated by either party (as defined in Eligibility Criteria). Conflicts at the abstract and full text review level were resolved by consensus.

We managed citations with Refworks (ProQuest, Bethesda, MD). Two reviewers sequentially abstracted information from the included articles on study design, population source, outpatient setting, acute care setting, follow-up period, and country using standardized forms (see online supplement). We extracted the following information on communication: frequency of the provider-to-provider communication, directionality of the communication (bidirectional, unidirectional), the method(s) of communication (e.g., telephone), the type(s) of outpatient providers involved in the communication, and the type(s) of acute care providers involved in the communication, and if there were specific factors associated with provider-to-provider communication (see online supplement). For outcomes, we extracted sample sizes, measures of association and confidence intervals, and whether there were any stratified analyses (see online supplement).

Synthesis

We conducted a qualitative synthesis by summarizing study characteristics and results in tables. For the available outcomes, the principal summary measure was odds ratio. We calculated odds ratios and 95 % confidence intervals using Woolf’s13 method when sufficient quantitative data were provided. We did not plan to conduct quantitative synthesis with meta-analysis, given the expected heterogeneity of studies.

Bias Assessment

Risk of bias was assessed independently by two reviewers using the internal validity questions as described by Downs and Black (see Appendix C online).14 We did not exclude studies on the basis of risk of bias.

Registration

We registered our systematic review protocol through PROSPERO; Registration Number: CRD42014010376.

RESULTS

Description of Studies

Of 4009 initial citations, we included 20 articles for data extraction (Fig. 1): 13 cross-sectional studies,15 – 27 four cohort studies,28 – 31 two randomized controlled trials,32 , 33 and one quasi-experimental study34 (Table 1). Studies were conducted in the US (n = 11),15 – 21 , 24 , 28 , 29 , 34 Australia (n = 6),22 , 25 , 30 – 33 and United Kingdom (n = 3).23 , 26 , 27 Most studies evaluated the transition from outpatient clinic to hospital admission (n = 9).16 , 19 , 21 – 23 , 25 , 27 , 28 , 32 Other described transitions included nursing home to the emergency department (four studies),17 , 18 , 20 , 34 clinic to the emergency department (four studies),26 , 30 , 31 , 33 and three from an unspecified site to hospital admission.15 , 24 , 29

Figure 1
figure 1

Flow diagram of article selection.

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Table 1 Characteristics of Included Studies (n = 20)
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Overall, the majority of the acute care settings involved are individual hospitals.15 , 16 , 19 , 21 – 25 , 27 , 28 , 30 , 32 , 33 Three studies noted academic centers as the acute care setting15 , 16 , 19 and four other studies described a “district hospital’s” involvement.23 , 27 , 30 , 33 None of the studies reviewed clearly stated that the study involved integrated health systems (see Table 1).

Provider-to-Provider Communication Quantitative Results

Fourteen of the 20 (70 %) articles15 , 16 , 21 – 24 , 27 – 34 reported quantitative results on the occurrence of provider-to-provider communication (Table 2).

Table 2 Provider-to-Provider Communication: Direction, Mode and Frequency (n = 14)
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Frequency of Communication

There was substantial heterogeneity in how each study defined direct communication between providers. Out of the 14 studies with quantitative data, seven reported numerical frequencies of direct communication. The two studies reporting the highest direct communication rates were ones that used telephone contact as the mode of communication: 1) between a hospitalist to a primary care provider (69 %)28; and 2) a medical resident telephoning a primary care provider (70.5 %).24 Direct communication via referral letters was only moderately successful, either via electronic referrals (21 %)34 or written referrals from the general practitioner taken to the emergency department (19.7 %).31 One study21 utilized medical record review to confirm if an inpatient provider had documented whether they notified the outpatient provider, and that had the lowest rate of direct communication; only 9.5 % of the medical records reviewed documented communication between an inpatient team and primary care provider. Finally, two studies15 , 29 noted the direct communication frequency, but it was unclear via what mode(s) communication occurred.

Types of Providers Involved in the Communication

Thirteen of 14 articles (93 %) 15 , 16 , 21 – 23 , 27 – 33 identified primary care providers/general practitioners as the predominant outpatient provider involved in the communication (see Table 2). Among those 13 studies, eight described communication with an inpatient medical provider (62 %),15 , 16 , 21 – 24 , 27 , 28 three reported communication with the emergency department provider (23 %),30 , 31 , 33 one with an inpatient pharmacist (8 %),32 and one study did not specify the acute care provider (8 %).29

One additional study reported communication between the nursing home staff and the emergency department staff. Though this study did not exclusively report direct communication between providers, it did include their assessment of the provider-to-provider communication from the nursing home to emergency department setting; thus, it was included.34

Mode of Communication

Among the 14 studies,15 , 16 , 21 – 24 , 27 – 34 multiple modes of communication were described (Table 2). Providers in five of 14 studies (36 %) communicated with referral letters, either sent in with patients or sent electronically;23 , 30 , 31 , 33 , 34 four studies (29 %) described providers communicating via telephone calls;24 , 28 , 30 , 32 three studies (21 %) involved communication via fax;16 , 32 , 33 and one study described providers reviewing notes from the medical record to ascertain whether the inpatient provider had documented communication with the primary care provider at admission or not.21 The remaining four studies (29 %) did not explicitly report on the mode of communication, though all noted that successful communication did occur with the outpatient provider.15 , 22 , 27 , 29

Directionality of Communication

Among the 14 studies reporting on frequency of communication, four (29 %) involved unidirectional communication23 , 28 , 30 , 31 and five (36 %) reported bidirectional communication16 , 24 , 32 – 34 (Table 2). Directionality of the remaining five studies was unclear.15 , 21 , 22 , 27 , 29 An example of unidirectional communication was general practitioners sending in referral letters with patients to be given to the ED provider.31An example of bidirectional communication was an inpatient provider telephoning the primary care provider.24 Directionality of communication did not seem to be related to the frequency of communication.

Outcomes

Only six of 20 studies (30 %) evaluated outcomes associated with provider-to-provider communication.15 , 21 , 22 , 24 , 29 , 32 , 34

Three studies evaluated readmissions (see Table 3). Two of those studies noted that the occurrence of communication (direct communication with a primary care provider29 and participation in a medication liaison service intervention32) was associated with non-statistically significant decreases in odds of 30-day readmissions when compared to usual care, and the other study found no association between communication and readmissions (OR 1.08, 95 % CI 0.92-1.26).15 One of these studies also found non-statistically significant improvements in 30-day mortality and 30-day ED visits with communication (see Table 3).29 Stowasser et al. also noted a non-significant decrease in the utilization of community healthcare resources within 30 days of discharge for those who participated in a medication liaison service in which inpatient pharmacists communicated with the general practitioner and community pharmacist about medication reviews compared to the control group, which did not have this communication.32

Table 3 Association Between Communication and Health Care Utilization (n=3)
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Finally, three studies evaluated patient or provider satisfaction. Stowasser et al.22 and Zamora et al.34 both found that providers reported high satisfaction with interventions to promote direct provider-to-provider communication. Hruby et al.’s21 study of patient satisfaction reported that 90 % of patients surveyed noted that they were satisfied with the communication between the inpatient team and their primary care provider.

Risk of Bias

As the majority of studies were observational, we utilized 13 of the most relevant questions from the Downs and Black risk of bias tool (see Appendix C online).14 The majority of studies were noted to have high risk of bias. Figure 2 highlights five of the 13 quality items evaluated. The full results of the risk of bias are shown in the online supplement.

Figure 2
figure 2

Risk of bias assessment selected results (n = 20)

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DISCUSSION

We found few studies evaluating provider-to-provider communication at the transition from outpatient to acute care, and the majority of these were cross-sectional. The frequency of communication ranged widely across the studies reporting on this, and few studies reported on either clinical or satisfaction outcomes. The majority of the communication between outpatient and acute care providers consisted of primary care providers and general practitioners communicating with inpatient medical providers (hospitalists, admitting doctors, medical residents). Bidirectional communication was slightly more common than unidirectional communication (36 % vs. 29 %, respectively), but it was often unclear who was initiating bidirectional communication. The highest rate of communication was via telephone calls. The advantage of this mode is that it allows for synchronous bidirectional communication between providers, decreasing chances of miscommunication. The main disadvantage is successfully reaching the intended providers in a timely manner. If direct communication can improve the inbound outpatient to acute care transition, then future interventions/policies should explore ways to incentivize providers on both sides of the transition to prioritize this mode. The second most frequent mode was via referral letters. Interestingly, referral letters were only done in Australia and the United Kingdom,23 , 30 , 31 , 33 and none were done in the United States.

While most (five of six) studies reporting on outcomes (30-day readmissions, mortality, ED visits, resource utilization, patient and provider satisfaction) observed better outcomes with successful communication, none of the findings were statistically significant (p < 0.05). Notably, these studies may have been underpowered for these outcomes, given their sample size, event rates, and frequency of communication.

Provider-to-provider communication is important to mitigate the information gap that commonly occurs when patient-related information is not available to the provider at point of care. One study35 noted that one-third of visits to their emergency department had information gaps. This information gap could be addressed through consistent provider-to-provider communication.

Our findings on the transition from the outpatient to acute care setting complement those found for the inpatient to outpatient transition for which there is an extensive literature. Kripalani et al.5 noted the substantial deficits in communication between providers at times of discharge.5 Discontinuity in the transition from inpatient to outpatient care has been shown to lead to medical errors and patient safety concerns, ranging from lab and radiology results pending on hospital discharge36 to adverse drug reactions37 to readmissions.10 Moreover, Hesselink et al.,38 in their review of patient handovers from hospital back to primary care, concluded that multicomponent interventions were most effective. The effective interventions usually included careful medication review, use of electronic health records to transfer information to the primary care provider, provider access to electronic discharge information, and shared involvement between the hospital and outpatient providers.38 Awareness on both the acute care and outpatient providers of the need for communication at these critical junctures of transitions is key.

The major limitation to this systematic review is a lack of high-quality studies evaluating provider-to-provider communication during the transition from the outpatient to acute care setting. Heterogeneity of the studies also limited our ability to quantitatively synthesize results. We excluded non-English language articles, limiting the generalizability of our findings to non-English-speaking countries that may have different approaches to provider-to-provider communication based on culture and infrastructure when compared to the countries where our articles were derived. For example, though the French health system also has universal coverage like Australia and the United Kingdom, they currently have two different electronic health systems, one that provides information on hospital admissions and the other on outpatient and hospital claims. On the other hand, the Danish health system has a sophisticated electronic medical system in which all general practitioners have access to the discharge letters and can place electronic referrals.39

To our knowledge, this is the first systematic review to study provider-to-provider communication during the transition from the outpatient to acute care setting. We found that the literature on this transition is sparse and heterogeneous, and consists of low-quality studies that are not conclusive. Given the established importance of communication at the time of the transition from the acute care to outpatient setting,11 the best ways for this communication to occur during the transition from outpatient to acute care setting (e.g., roles and responsibilities, modes of communication) need to be established. In particular, future studies should determine which communication interventions improve important outcomes such as mortality, morbidity, length of stay and costs. Overall, the evidence on provider-to-provider communication at the transition from the outpatient to acute care setting is insufficient, and is an area of great potential for improving patient care.