Discharge Summaries and Readmissions

Across the continuum of care, the discharge summary is a critical tool for communication among care providers.[1] In the United States, the Joint Commission policies mandate that all hospital providers complete a discharge summary for patients with specific components to foster effective communication with future providers.[2] Because outpatient providers and emergency physicians rely on clinical information in the discharge summary to ensure appropriate postdischarge continuity of care, timely documentation is potentially an essential aspect of readmission reduction initiatives.[3, 4, 5] Prior reports indicate that poor discharge documentation of follow‐up plan‐of‐care increases the risk of hospitalization, whereas structured instructions, patient education, and direct communications with primary care physicians (PCPs) reduce repeat hospital visits.[6, 7, 8, 9] However, the current literature is limited in its narrow focus on the contents of discharge summaries, considered only same‐hospital readmissions, or considered readmissions within 3 months of discharge.[10, 11, 12, 13] Moreover, some prior research has suggested no association between discharge summary timeliness with readmission,[12, 13, 14] whereas another study did find a relationship,[15] hence the need to study this further is important. Filling this gap in knowledge could provide an avenue to track and improve quality of patient care, as delays in discharge summaries have been linked with pot‐discharge adverse outcomes and patient safety concerns.[15, 16, 17, 18] Because readmissions often occur soon after discharge, having timely discharge summaries may be particularly important to outcomes.[19, 20]

This research began under the framework of evaluating a bundle of care coordination strategies that were implemented at the Johns Hopkins Health System. These strategies were informed by the early Centers for Medicare and Medicaid Services (CMS) demonstration projects and other best practices that have been documented in the literature to improve utilization and improve communication during transitions of care.[21, 22, 23, 24, 25] Later they were augmented through a contract with the Center of Medicare and Medicaid Innovation to improve access to healthcare services and improve patient outcomes through improved care coordination processes. One of the domains our institution has increased efforts to improve is in provider handoffs. Toward that goal, we have worked to disentangle the effects of different factors of provider‐to‐provider communication that may influence readmissions.[26] For example, effective written provider handoffs in the form of accurate and timely discharge summaries was considered a key care coordination component of this program, but there was institutional resistance to endorsing an expectation that discharge summary turnaround should be shortened. To build a case for this concept, we sought to test the hypothesis that, at our hospital, longer time to complete hospital discharge summaries was associated with increased readmission rates. Unique to this analysis is that, in the state of Maryland, there is statewide reporting of readmissions, so we were able to account for intra‐ and interhospital readmissions for an all‐payer population. The authors anticipated that findings from this study would help inform discharge quality‐improvement initiatives and reemphasize the importance of timely discharge documentation across all disciplines as part of quality patient care.

METHODS

RESULTS

Association Between Days to Complete the Discharge Summary and Readmission

After hospital discharge, median (IQR) number of days to complete discharge summaries was 8 (416) days. After hospital discharge, median (IQR) number of days to complete discharge summaries and the number of days from discharge to readmission was 8 (416) and 11 (519) days, respectively (P < 0.001). Six thousand one hundred one patients (42.8%) were readmitted before their discharge summary was completed. The median (IQR) days to complete discharge summaries by hospital service in order from shortest to longest was: oncology, 6 (212) days; surgical sciences, 6 (312) days; pediatrics, 7 (315) days; gynecologyobstetrics, 8 (415) days; medicine, 9 (420) days; neurosciences, 12 (621) days.

When we divided the number of days to complete the discharge summary into deciles (02, 2.13, 3.14, 4.16, 6.18, 8.210, 10.114, 14.119, 19.130, >30), a longer number of days to complete discharge summaries had higher unadjusted and adjusted readmission rates (Figure 1). In unadjusted analysis, Table 2 shows that older age, male sex, African American race, oncological versus medicine hospital service, discharge location, longer LOS, higher APRDRG‐SOI expected readmission rate, and higher AHRQ Comorbidity Index were associated with readmission. Days to complete the discharge summary >3 days versus 3 days was associated with a higher readmission rate, with an unadjusted odds ratio (OR) and 95% confidence interval (CI) of 1.09 (95% CI: 1.04 to 1.13, P < 0.001).

Table 2.Association Between Patient Characteristics, Discharge Summary Completion >3 Days, and 30‐Day Readmission Status

Characteristic	Bivariable Analysis*		Multivariable Analysis*
	OR (95% CI)	P Value	OR (95% CI)	P Value
NOTE: Abbreviations: AHRQ, Agency for Healthcare Research and Quality; APRDRG, All‐PayerRefined Diagnosis‐Related Group; CI, confidence interval; OR, odds ratio; SNF, skilled nursing facility; SOI, severity of illness. *Calculated using logistic regression analysis.
Age, 10 y	1.09 (1.08 to 1.09)	<0.001	0.97 (0.95 to 0.98)	<0.001
Male	1.13 (1.09 to 1.17)	<0.001	1.01 (0.97 to 1.05)	0.76
Race
Caucasian	Referent		Referent
African American	1.21 (1.17 to 1.26)	<0.001	1.01 (0.96 to 1.05)	0.74
Other	0.84 (0.79 to 0.90)	<0.001	0.92 (0.86 to 0.98)	0.01
Payer
Medicare	Referent		Referent
Medicaid	0.74 (0.70 to 0.77)	<0.001	1.03 (0.97 to 1.09)	0.42
Other	0.57 (0.55 to 0.60)	<0.001	0.86 (0.82 to 0.91)	<0.001
Hospital service
Medicine	Referent		Referent
Gynecologyobstetrics	0.18 (0.16 to 0.20)	<0.001	0.50 (0.45 to 0.56)	<0.001
Neurosciences	0.43 (0.40 to 0.46)	<0.001	0.76 (0.70 to 0.82)	<0.001
Oncology	1.14 (1.07 to 1.22)	<0.001	1.18 (1.10 to 1.28)	<0.001
Pediatrics	0.54 (0.51 to 0.57)	<0.001	0.77 (0.71 to 0.83)	<0.001
Surgical sciences	0.57 (0.54 to 0.60)	<0.001	0.92 (0.87 to 0.97)	0.002
Discharge location
Home			Referent
Facility (SNF, rehabilitation facility)	1.90 (1.77 to 2.03)	<0.001	1.11 (1.02 to 1.19)	0.009
Home with homecare or hospice	1.73 (1.64 to 1.83)	<0.001	1.26 (1.19 to 1.34)	<0.001
Other	1.89 (1.78 to 2.00)	<0.001	1.25 (1.18 to 1.34)	<0.001
Length of stay, d	1.03 (1.02 to 1.03)	<0.001	1.00 (1.00 to 1.01)	<0.001
APRDRG‐SOI expected readmission rate, %	1.08 (1.07 to 1.08)	<0.001	1.06 (1.06 to 1.06)	<0.001
AHRQ Comorbidity Index (1 point)	1.27 (1.26 to 1.28)	<0.001	1.11 (1.09 to 1.12)	<0.001
Discharge summary completed >3 days	1.09 (1.04 to 1.14)	<0.001	1.09 (1.05 to 1.14)	<0.001

Figure 1

DISCUSSION

In this single‐center retrospective analysis, the number of days to complete the discharge summary was significantly associated with readmissions after hospitalization. This association was independent of age, gender, comorbidity index, payer, discharge location, length of hospital stay, expected readmission rate based on diagnosis and severity of illness, and all hospital services. The odds of readmission for patients with delayed discharge summaries was small but significant. This is important in the current landscape of readmissions, particularly for institutions who are challenged to reduce readmission rates, and a small relative difference in readmissions may be the difference between getting penalized or not. In the context of prior studies, the results highlight the role of timely discharge summary as an under‐recognized metric, which may be a valid litmus test for care coordination. The findings also emphasize the potential of early summaries to expedite communication and to help facilitate quality of patient care. Hence, the study results extend the literature examining the relationship of delay in discharge summary with unfavorable patient outcomes.[15, 32]

In contrast to prior reports with limited focus on same‐hospital readmissions,[18, 33, 34, 35] readmissions beyond 30 days,[12] or focused on a specific patient population,[13, 36] this study evaluates both intra‐ and interhospital 30‐day readmissions in Maryland in an all‐payer, multi‐institution, diverse patient population. Additionally, prior research is conflicting with respect to whether timely discharges summaries are significantly associated with increased hospital readmissions.[12, 13, 14, 15] Although it is not surprising that inadequate care during hospitalization could result in readmissions, the role of discharge summaries remain underappreciated. Having a timely discharge summary may not always prevent readmissions, but our study showed that 43% of readmission occurred before the discharge summary completion. Not having a completed discharge summary at the time of readmission may have been a driver for the positive association between timely completion and 30‐day readmission we observed. This study highlights that delay in the discharge summary could be a marker of poor transitions of care, because suboptimal dissemination of critical information to care providers may result in discontinuity of patient care posthospitalization.

A plausible mechanism of the association between discharge summary delays and readmissions could be the provision of collateral information, which may potentially alter the threshold for readmissions. For example, in the emergency room/emergency department (ER/ED) setting, discharge summaries may help with preventable readmissions. For patients who present repeatedly with the same complaint, timely summaries to ER/ED providers may help reframe the patient complaints, such as patient has concern X, which was previously identified to be related to diagnosis Y. As others have shown, the content of discharge summaries, format, and accessibility (electronic vs paper chart), as well as timely distribution of summaries, are key factors that impact quality outcomes.[2, 12, 15, 37, 38] By detailing prior hospital information (ie, discharge medications, prior presentations, tests completed), summaries could help prevent errors in medication dosing, reduce unnecessary testing, and help facilitate admission triage. Summaries may have information regarding a new diagnosis such as the results of an endoscopic evaluation that revealed the source of occult gastrointestinal bleeding, which could help contextualize a complaint of repeat melena and redirect goals of care. Discussions of goals of care in the discharge summary may guide primary providers in continued care management plans.

Our study findings underscore a positive correlation between late discharge summaries and readmissions. However, the extent that this is a causal relationship is unclear; the association of delay in days to complete the discharge summary with readmission may be an epiphenomenon related to processes related to quality of clinical care. For example, delays in discharge summary completion could be a marker of other system issues, such as a stressed work environment. It is possible that providers who fail to complete timely discharge summaries may also fail to do other important functions related to transitions of care and care coordination. However, even if this is so, timely discharge summaries could become a focal point for discussion for optimization of care transitions. A discharge summary could be delayed because the patient has already been readmitted before the summary was distributed, thus making that original summary less relevant. Delays could also be a reflection of the data complexity for patients with longer hospital stays. This is supported by the small but significant relationship between LOS and days to complete the discharge summary in this study. Lastly, delays in discharge summary completion may also be a proxy of provider communication and can reflect the culture of communication at the institution.

Although unplanned hospital readmission is an important outcome, many readmissions may be related to other factors such as disease progression, rather than late summaries or the lack of postdischarge communication. For instance, prior reports did not find any association between the PCP seeing the discharge summaries or direct communications with the PCP and 30‐day clinical outcomes for readmission and death.[26, 39] However, these studies were limited in their use of self‐reported handoffs, did not measure quality of information transfer, and failed to capture a broader audience beyond the PCP, such as ED physicians or specialists.

Our results suggest that the relationship between days to complete discharge summaries and 30‐day readmissions may vary depending on whether the hospitalization is primarily surgical/procedural versus medical treatment. A recent study found that most readmissions after surgery were associated with new complications related to the procedure and not exacerbation of prior index hospitalization complications.[40] Hence, treatment for common causes of hospital readmissions after surgical or gynecological procedures, such as wound infections, acute anemia, ileus, or dehydration, may not necessarily require a completed discharge summary for appropriate management. However, we caution extending this finding to clinical practice before further studies are conducted on specific procedures and in different clinical settings.

Results from this study also support institutional policies that specify the need for practitioners to complete discharge summaries contemporaneously, such as at the time of discharge or within a couple of days. Unlike other forms of communication that are optional, discharge summaries are required, so we recommend that practitioners be held accountable for short turnaround times. For example, providers could be graded and rated on timely completions of discharge summaries, among other performance variables. Anecdotally at our institutions, we have heard from practitioners that it takes less time to complete them when you do them on the day of discharge, because the hospitalization course is fresher in their mind and they have to wade through less information in the medical record to complete an accurate discharge summary. To this point, a barrier to on‐time completion is that providers may have misconceptions about what is really vital information to convey to the next provider. In agreement with past research and in the era of the electronic medical record system, we recommend that the discharge summary should be a quick synthesis of key findings that incorporates only the important elements, such as why the patient was hospitalized, what were key findings and key responses to therapy, what is pending at the time of discharge, what medications the patient is currently taking, and what are the follow‐up plans, rather than a lengthy expose of all the findings.[13, 36, 41, 42]

Lastly, our study results should be taken in the context of its limitations. As a single‐center study, findings may lack generalizability. In particular, the results may not generalize to hospitals that lack access to statewide reporting. We were also not able to assess readmission for patients who may have been readmitted to a hospital outside of Maryland. Although we adjusted for pertinent variables such as age, gender, healthcare payer, hospital service, comorbidity index, discharge location, LOS, and expected readmission rates, there may be other relevant confounders that we failed to capture or measure optimally. Median days to complete the discharge summary in this study was 8 days, which is longer than practices at other institutions, and may also limit this study's generalizability.[15, 36, 42] However, prior research supports our findings,[15] and a systematic review found that only 29% and 52% of discharge summaries were completed by 2 weeks and 4 weeks, respectively.[9] Finally, as noted above and perhaps most important, it is possible that discharge summary turnaround time does not in itself causally impact readmissions, but rather reflects an underlying commitment of the inpatient team to effectively coordinate care following hospital discharge.

CONCLUSION

In sum, this study delineates an underappreciated but important relationship of timely discharge summary completion and readmission outcomes. The discharge summary may be a relevant metric reflecting quality of patient care. Healthcare providers may begin to target timely discharge summaries as a potential focal point of quality‐improvement projects with the goal to facilitate better patient outcomes.

Across the continuum of care, the discharge summary is a critical tool for communication among care providers.[1] In the United States, the Joint Commission policies mandate that all hospital providers complete a discharge summary for patients with specific components to foster effective communication with future providers.[2] Because outpatient providers and emergency physicians rely on clinical information in the discharge summary to ensure appropriate postdischarge continuity of care, timely documentation is potentially an essential aspect of readmission reduction initiatives.[3, 4, 5] Prior reports indicate that poor discharge documentation of follow‐up plan‐of‐care increases the risk of hospitalization, whereas structured instructions, patient education, and direct communications with primary care physicians (PCPs) reduce repeat hospital visits.[6, 7, 8, 9] However, the current literature is limited in its narrow focus on the contents of discharge summaries, considered only same‐hospital readmissions, or considered readmissions within 3 months of discharge.[10, 11, 12, 13] Moreover, some prior research has suggested no association between discharge summary timeliness with readmission,[12, 13, 14] whereas another study did find a relationship,[15] hence the need to study this further is important. Filling this gap in knowledge could provide an avenue to track and improve quality of patient care, as delays in discharge summaries have been linked with pot‐discharge adverse outcomes and patient safety concerns.[15, 16, 17, 18] Because readmissions often occur soon after discharge, having timely discharge summaries may be particularly important to outcomes.[19, 20]

This research began under the framework of evaluating a bundle of care coordination strategies that were implemented at the Johns Hopkins Health System. These strategies were informed by the early Centers for Medicare and Medicaid Services (CMS) demonstration projects and other best practices that have been documented in the literature to improve utilization and improve communication during transitions of care.[21, 22, 23, 24, 25] Later they were augmented through a contract with the Center of Medicare and Medicaid Innovation to improve access to healthcare services and improve patient outcomes through improved care coordination processes. One of the domains our institution has increased efforts to improve is in provider handoffs. Toward that goal, we have worked to disentangle the effects of different factors of provider‐to‐provider communication that may influence readmissions.[26] For example, effective written provider handoffs in the form of accurate and timely discharge summaries was considered a key care coordination component of this program, but there was institutional resistance to endorsing an expectation that discharge summary turnaround should be shortened. To build a case for this concept, we sought to test the hypothesis that, at our hospital, longer time to complete hospital discharge summaries was associated with increased readmission rates. Unique to this analysis is that, in the state of Maryland, there is statewide reporting of readmissions, so we were able to account for intra‐ and interhospital readmissions for an all‐payer population. The authors anticipated that findings from this study would help inform discharge quality‐improvement initiatives and reemphasize the importance of timely discharge documentation across all disciplines as part of quality patient care.

METHODS

RESULTS

Association Between Days to Complete the Discharge Summary and Readmission

After hospital discharge, median (IQR) number of days to complete discharge summaries was 8 (416) days. After hospital discharge, median (IQR) number of days to complete discharge summaries and the number of days from discharge to readmission was 8 (416) and 11 (519) days, respectively (P < 0.001). Six thousand one hundred one patients (42.8%) were readmitted before their discharge summary was completed. The median (IQR) days to complete discharge summaries by hospital service in order from shortest to longest was: oncology, 6 (212) days; surgical sciences, 6 (312) days; pediatrics, 7 (315) days; gynecologyobstetrics, 8 (415) days; medicine, 9 (420) days; neurosciences, 12 (621) days.

When we divided the number of days to complete the discharge summary into deciles (02, 2.13, 3.14, 4.16, 6.18, 8.210, 10.114, 14.119, 19.130, >30), a longer number of days to complete discharge summaries had higher unadjusted and adjusted readmission rates (Figure 1). In unadjusted analysis, Table 2 shows that older age, male sex, African American race, oncological versus medicine hospital service, discharge location, longer LOS, higher APRDRG‐SOI expected readmission rate, and higher AHRQ Comorbidity Index were associated with readmission. Days to complete the discharge summary >3 days versus 3 days was associated with a higher readmission rate, with an unadjusted odds ratio (OR) and 95% confidence interval (CI) of 1.09 (95% CI: 1.04 to 1.13, P < 0.001).

Table 2.Association Between Patient Characteristics, Discharge Summary Completion >3 Days, and 30‐Day Readmission Status

Characteristic	Bivariable Analysis*		Multivariable Analysis*
	OR (95% CI)	P Value	OR (95% CI)	P Value
NOTE: Abbreviations: AHRQ, Agency for Healthcare Research and Quality; APRDRG, All‐PayerRefined Diagnosis‐Related Group; CI, confidence interval; OR, odds ratio; SNF, skilled nursing facility; SOI, severity of illness. *Calculated using logistic regression analysis.
Age, 10 y	1.09 (1.08 to 1.09)	<0.001	0.97 (0.95 to 0.98)	<0.001
Male	1.13 (1.09 to 1.17)	<0.001	1.01 (0.97 to 1.05)	0.76
Race
Caucasian	Referent		Referent
African American	1.21 (1.17 to 1.26)	<0.001	1.01 (0.96 to 1.05)	0.74
Other	0.84 (0.79 to 0.90)	<0.001	0.92 (0.86 to 0.98)	0.01
Payer
Medicare	Referent		Referent
Medicaid	0.74 (0.70 to 0.77)	<0.001	1.03 (0.97 to 1.09)	0.42
Other	0.57 (0.55 to 0.60)	<0.001	0.86 (0.82 to 0.91)	<0.001
Hospital service
Medicine	Referent		Referent
Gynecologyobstetrics	0.18 (0.16 to 0.20)	<0.001	0.50 (0.45 to 0.56)	<0.001
Neurosciences	0.43 (0.40 to 0.46)	<0.001	0.76 (0.70 to 0.82)	<0.001
Oncology	1.14 (1.07 to 1.22)	<0.001	1.18 (1.10 to 1.28)	<0.001
Pediatrics	0.54 (0.51 to 0.57)	<0.001	0.77 (0.71 to 0.83)	<0.001
Surgical sciences	0.57 (0.54 to 0.60)	<0.001	0.92 (0.87 to 0.97)	0.002
Discharge location
Home			Referent
Facility (SNF, rehabilitation facility)	1.90 (1.77 to 2.03)	<0.001	1.11 (1.02 to 1.19)	0.009
Home with homecare or hospice	1.73 (1.64 to 1.83)	<0.001	1.26 (1.19 to 1.34)	<0.001
Other	1.89 (1.78 to 2.00)	<0.001	1.25 (1.18 to 1.34)	<0.001
Length of stay, d	1.03 (1.02 to 1.03)	<0.001	1.00 (1.00 to 1.01)	<0.001
APRDRG‐SOI expected readmission rate, %	1.08 (1.07 to 1.08)	<0.001	1.06 (1.06 to 1.06)	<0.001
AHRQ Comorbidity Index (1 point)	1.27 (1.26 to 1.28)	<0.001	1.11 (1.09 to 1.12)	<0.001
Discharge summary completed >3 days	1.09 (1.04 to 1.14)	<0.001	1.09 (1.05 to 1.14)	<0.001

Figure 1

DISCUSSION

In this single‐center retrospective analysis, the number of days to complete the discharge summary was significantly associated with readmissions after hospitalization. This association was independent of age, gender, comorbidity index, payer, discharge location, length of hospital stay, expected readmission rate based on diagnosis and severity of illness, and all hospital services. The odds of readmission for patients with delayed discharge summaries was small but significant. This is important in the current landscape of readmissions, particularly for institutions who are challenged to reduce readmission rates, and a small relative difference in readmissions may be the difference between getting penalized or not. In the context of prior studies, the results highlight the role of timely discharge summary as an under‐recognized metric, which may be a valid litmus test for care coordination. The findings also emphasize the potential of early summaries to expedite communication and to help facilitate quality of patient care. Hence, the study results extend the literature examining the relationship of delay in discharge summary with unfavorable patient outcomes.[15, 32]

In contrast to prior reports with limited focus on same‐hospital readmissions,[18, 33, 34, 35] readmissions beyond 30 days,[12] or focused on a specific patient population,[13, 36] this study evaluates both intra‐ and interhospital 30‐day readmissions in Maryland in an all‐payer, multi‐institution, diverse patient population. Additionally, prior research is conflicting with respect to whether timely discharges summaries are significantly associated with increased hospital readmissions.[12, 13, 14, 15] Although it is not surprising that inadequate care during hospitalization could result in readmissions, the role of discharge summaries remain underappreciated. Having a timely discharge summary may not always prevent readmissions, but our study showed that 43% of readmission occurred before the discharge summary completion. Not having a completed discharge summary at the time of readmission may have been a driver for the positive association between timely completion and 30‐day readmission we observed. This study highlights that delay in the discharge summary could be a marker of poor transitions of care, because suboptimal dissemination of critical information to care providers may result in discontinuity of patient care posthospitalization.

A plausible mechanism of the association between discharge summary delays and readmissions could be the provision of collateral information, which may potentially alter the threshold for readmissions. For example, in the emergency room/emergency department (ER/ED) setting, discharge summaries may help with preventable readmissions. For patients who present repeatedly with the same complaint, timely summaries to ER/ED providers may help reframe the patient complaints, such as patient has concern X, which was previously identified to be related to diagnosis Y. As others have shown, the content of discharge summaries, format, and accessibility (electronic vs paper chart), as well as timely distribution of summaries, are key factors that impact quality outcomes.[2, 12, 15, 37, 38] By detailing prior hospital information (ie, discharge medications, prior presentations, tests completed), summaries could help prevent errors in medication dosing, reduce unnecessary testing, and help facilitate admission triage. Summaries may have information regarding a new diagnosis such as the results of an endoscopic evaluation that revealed the source of occult gastrointestinal bleeding, which could help contextualize a complaint of repeat melena and redirect goals of care. Discussions of goals of care in the discharge summary may guide primary providers in continued care management plans.

Our study findings underscore a positive correlation between late discharge summaries and readmissions. However, the extent that this is a causal relationship is unclear; the association of delay in days to complete the discharge summary with readmission may be an epiphenomenon related to processes related to quality of clinical care. For example, delays in discharge summary completion could be a marker of other system issues, such as a stressed work environment. It is possible that providers who fail to complete timely discharge summaries may also fail to do other important functions related to transitions of care and care coordination. However, even if this is so, timely discharge summaries could become a focal point for discussion for optimization of care transitions. A discharge summary could be delayed because the patient has already been readmitted before the summary was distributed, thus making that original summary less relevant. Delays could also be a reflection of the data complexity for patients with longer hospital stays. This is supported by the small but significant relationship between LOS and days to complete the discharge summary in this study. Lastly, delays in discharge summary completion may also be a proxy of provider communication and can reflect the culture of communication at the institution.

Although unplanned hospital readmission is an important outcome, many readmissions may be related to other factors such as disease progression, rather than late summaries or the lack of postdischarge communication. For instance, prior reports did not find any association between the PCP seeing the discharge summaries or direct communications with the PCP and 30‐day clinical outcomes for readmission and death.[26, 39] However, these studies were limited in their use of self‐reported handoffs, did not measure quality of information transfer, and failed to capture a broader audience beyond the PCP, such as ED physicians or specialists.

Our results suggest that the relationship between days to complete discharge summaries and 30‐day readmissions may vary depending on whether the hospitalization is primarily surgical/procedural versus medical treatment. A recent study found that most readmissions after surgery were associated with new complications related to the procedure and not exacerbation of prior index hospitalization complications.[40] Hence, treatment for common causes of hospital readmissions after surgical or gynecological procedures, such as wound infections, acute anemia, ileus, or dehydration, may not necessarily require a completed discharge summary for appropriate management. However, we caution extending this finding to clinical practice before further studies are conducted on specific procedures and in different clinical settings.

Results from this study also support institutional policies that specify the need for practitioners to complete discharge summaries contemporaneously, such as at the time of discharge or within a couple of days. Unlike other forms of communication that are optional, discharge summaries are required, so we recommend that practitioners be held accountable for short turnaround times. For example, providers could be graded and rated on timely completions of discharge summaries, among other performance variables. Anecdotally at our institutions, we have heard from practitioners that it takes less time to complete them when you do them on the day of discharge, because the hospitalization course is fresher in their mind and they have to wade through less information in the medical record to complete an accurate discharge summary. To this point, a barrier to on‐time completion is that providers may have misconceptions about what is really vital information to convey to the next provider. In agreement with past research and in the era of the electronic medical record system, we recommend that the discharge summary should be a quick synthesis of key findings that incorporates only the important elements, such as why the patient was hospitalized, what were key findings and key responses to therapy, what is pending at the time of discharge, what medications the patient is currently taking, and what are the follow‐up plans, rather than a lengthy expose of all the findings.[13, 36, 41, 42]

Lastly, our study results should be taken in the context of its limitations. As a single‐center study, findings may lack generalizability. In particular, the results may not generalize to hospitals that lack access to statewide reporting. We were also not able to assess readmission for patients who may have been readmitted to a hospital outside of Maryland. Although we adjusted for pertinent variables such as age, gender, healthcare payer, hospital service, comorbidity index, discharge location, LOS, and expected readmission rates, there may be other relevant confounders that we failed to capture or measure optimally. Median days to complete the discharge summary in this study was 8 days, which is longer than practices at other institutions, and may also limit this study's generalizability.[15, 36, 42] However, prior research supports our findings,[15] and a systematic review found that only 29% and 52% of discharge summaries were completed by 2 weeks and 4 weeks, respectively.[9] Finally, as noted above and perhaps most important, it is possible that discharge summary turnaround time does not in itself causally impact readmissions, but rather reflects an underlying commitment of the inpatient team to effectively coordinate care following hospital discharge.

CONCLUSION

In sum, this study delineates an underappreciated but important relationship of timely discharge summary completion and readmission outcomes. The discharge summary may be a relevant metric reflecting quality of patient care. Healthcare providers may begin to target timely discharge summaries as a potential focal point of quality‐improvement projects with the goal to facilitate better patient outcomes.

Across the continuum of care, the discharge summary is a critical tool for communication among care providers.[1] In the United States, the Joint Commission policies mandate that all hospital providers complete a discharge summary for patients with specific components to foster effective communication with future providers.[2] Because outpatient providers and emergency physicians rely on clinical information in the discharge summary to ensure appropriate postdischarge continuity of care, timely documentation is potentially an essential aspect of readmission reduction initiatives.[3, 4, 5] Prior reports indicate that poor discharge documentation of follow‐up plan‐of‐care increases the risk of hospitalization, whereas structured instructions, patient education, and direct communications with primary care physicians (PCPs) reduce repeat hospital visits.[6, 7, 8, 9] However, the current literature is limited in its narrow focus on the contents of discharge summaries, considered only same‐hospital readmissions, or considered readmissions within 3 months of discharge.[10, 11, 12, 13] Moreover, some prior research has suggested no association between discharge summary timeliness with readmission,[12, 13, 14] whereas another study did find a relationship,[15] hence the need to study this further is important. Filling this gap in knowledge could provide an avenue to track and improve quality of patient care, as delays in discharge summaries have been linked with pot‐discharge adverse outcomes and patient safety concerns.[15, 16, 17, 18] Because readmissions often occur soon after discharge, having timely discharge summaries may be particularly important to outcomes.[19, 20]

This research began under the framework of evaluating a bundle of care coordination strategies that were implemented at the Johns Hopkins Health System. These strategies were informed by the early Centers for Medicare and Medicaid Services (CMS) demonstration projects and other best practices that have been documented in the literature to improve utilization and improve communication during transitions of care.[21, 22, 23, 24, 25] Later they were augmented through a contract with the Center of Medicare and Medicaid Innovation to improve access to healthcare services and improve patient outcomes through improved care coordination processes. One of the domains our institution has increased efforts to improve is in provider handoffs. Toward that goal, we have worked to disentangle the effects of different factors of provider‐to‐provider communication that may influence readmissions.[26] For example, effective written provider handoffs in the form of accurate and timely discharge summaries was considered a key care coordination component of this program, but there was institutional resistance to endorsing an expectation that discharge summary turnaround should be shortened. To build a case for this concept, we sought to test the hypothesis that, at our hospital, longer time to complete hospital discharge summaries was associated with increased readmission rates. Unique to this analysis is that, in the state of Maryland, there is statewide reporting of readmissions, so we were able to account for intra‐ and interhospital readmissions for an all‐payer population. The authors anticipated that findings from this study would help inform discharge quality‐improvement initiatives and reemphasize the importance of timely discharge documentation across all disciplines as part of quality patient care.

METHODS

RESULTS

Association Between Days to Complete the Discharge Summary and Readmission

After hospital discharge, median (IQR) number of days to complete discharge summaries was 8 (416) days. After hospital discharge, median (IQR) number of days to complete discharge summaries and the number of days from discharge to readmission was 8 (416) and 11 (519) days, respectively (P < 0.001). Six thousand one hundred one patients (42.8%) were readmitted before their discharge summary was completed. The median (IQR) days to complete discharge summaries by hospital service in order from shortest to longest was: oncology, 6 (212) days; surgical sciences, 6 (312) days; pediatrics, 7 (315) days; gynecologyobstetrics, 8 (415) days; medicine, 9 (420) days; neurosciences, 12 (621) days.

When we divided the number of days to complete the discharge summary into deciles (02, 2.13, 3.14, 4.16, 6.18, 8.210, 10.114, 14.119, 19.130, >30), a longer number of days to complete discharge summaries had higher unadjusted and adjusted readmission rates (Figure 1). In unadjusted analysis, Table 2 shows that older age, male sex, African American race, oncological versus medicine hospital service, discharge location, longer LOS, higher APRDRG‐SOI expected readmission rate, and higher AHRQ Comorbidity Index were associated with readmission. Days to complete the discharge summary >3 days versus 3 days was associated with a higher readmission rate, with an unadjusted odds ratio (OR) and 95% confidence interval (CI) of 1.09 (95% CI: 1.04 to 1.13, P < 0.001).

Table 2.Association Between Patient Characteristics, Discharge Summary Completion >3 Days, and 30‐Day Readmission Status

Characteristic	Bivariable Analysis*		Multivariable Analysis*
	OR (95% CI)	P Value	OR (95% CI)	P Value
NOTE: Abbreviations: AHRQ, Agency for Healthcare Research and Quality; APRDRG, All‐PayerRefined Diagnosis‐Related Group; CI, confidence interval; OR, odds ratio; SNF, skilled nursing facility; SOI, severity of illness. *Calculated using logistic regression analysis.
Age, 10 y	1.09 (1.08 to 1.09)	<0.001	0.97 (0.95 to 0.98)	<0.001
Male	1.13 (1.09 to 1.17)	<0.001	1.01 (0.97 to 1.05)	0.76
Race
Caucasian	Referent		Referent
African American	1.21 (1.17 to 1.26)	<0.001	1.01 (0.96 to 1.05)	0.74
Other	0.84 (0.79 to 0.90)	<0.001	0.92 (0.86 to 0.98)	0.01
Payer
Medicare	Referent		Referent
Medicaid	0.74 (0.70 to 0.77)	<0.001	1.03 (0.97 to 1.09)	0.42
Other	0.57 (0.55 to 0.60)	<0.001	0.86 (0.82 to 0.91)	<0.001
Hospital service
Medicine	Referent		Referent
Gynecologyobstetrics	0.18 (0.16 to 0.20)	<0.001	0.50 (0.45 to 0.56)	<0.001
Neurosciences	0.43 (0.40 to 0.46)	<0.001	0.76 (0.70 to 0.82)	<0.001
Oncology	1.14 (1.07 to 1.22)	<0.001	1.18 (1.10 to 1.28)	<0.001
Pediatrics	0.54 (0.51 to 0.57)	<0.001	0.77 (0.71 to 0.83)	<0.001
Surgical sciences	0.57 (0.54 to 0.60)	<0.001	0.92 (0.87 to 0.97)	0.002
Discharge location
Home			Referent
Facility (SNF, rehabilitation facility)	1.90 (1.77 to 2.03)	<0.001	1.11 (1.02 to 1.19)	0.009
Home with homecare or hospice	1.73 (1.64 to 1.83)	<0.001	1.26 (1.19 to 1.34)	<0.001
Other	1.89 (1.78 to 2.00)	<0.001	1.25 (1.18 to 1.34)	<0.001
Length of stay, d	1.03 (1.02 to 1.03)	<0.001	1.00 (1.00 to 1.01)	<0.001
APRDRG‐SOI expected readmission rate, %	1.08 (1.07 to 1.08)	<0.001	1.06 (1.06 to 1.06)	<0.001
AHRQ Comorbidity Index (1 point)	1.27 (1.26 to 1.28)	<0.001	1.11 (1.09 to 1.12)	<0.001
Discharge summary completed >3 days	1.09 (1.04 to 1.14)	<0.001	1.09 (1.05 to 1.14)	<0.001

Figure 1

DISCUSSION

In this single‐center retrospective analysis, the number of days to complete the discharge summary was significantly associated with readmissions after hospitalization. This association was independent of age, gender, comorbidity index, payer, discharge location, length of hospital stay, expected readmission rate based on diagnosis and severity of illness, and all hospital services. The odds of readmission for patients with delayed discharge summaries was small but significant. This is important in the current landscape of readmissions, particularly for institutions who are challenged to reduce readmission rates, and a small relative difference in readmissions may be the difference between getting penalized or not. In the context of prior studies, the results highlight the role of timely discharge summary as an under‐recognized metric, which may be a valid litmus test for care coordination. The findings also emphasize the potential of early summaries to expedite communication and to help facilitate quality of patient care. Hence, the study results extend the literature examining the relationship of delay in discharge summary with unfavorable patient outcomes.[15, 32]

In contrast to prior reports with limited focus on same‐hospital readmissions,[18, 33, 34, 35] readmissions beyond 30 days,[12] or focused on a specific patient population,[13, 36] this study evaluates both intra‐ and interhospital 30‐day readmissions in Maryland in an all‐payer, multi‐institution, diverse patient population. Additionally, prior research is conflicting with respect to whether timely discharges summaries are significantly associated with increased hospital readmissions.[12, 13, 14, 15] Although it is not surprising that inadequate care during hospitalization could result in readmissions, the role of discharge summaries remain underappreciated. Having a timely discharge summary may not always prevent readmissions, but our study showed that 43% of readmission occurred before the discharge summary completion. Not having a completed discharge summary at the time of readmission may have been a driver for the positive association between timely completion and 30‐day readmission we observed. This study highlights that delay in the discharge summary could be a marker of poor transitions of care, because suboptimal dissemination of critical information to care providers may result in discontinuity of patient care posthospitalization.

A plausible mechanism of the association between discharge summary delays and readmissions could be the provision of collateral information, which may potentially alter the threshold for readmissions. For example, in the emergency room/emergency department (ER/ED) setting, discharge summaries may help with preventable readmissions. For patients who present repeatedly with the same complaint, timely summaries to ER/ED providers may help reframe the patient complaints, such as patient has concern X, which was previously identified to be related to diagnosis Y. As others have shown, the content of discharge summaries, format, and accessibility (electronic vs paper chart), as well as timely distribution of summaries, are key factors that impact quality outcomes.[2, 12, 15, 37, 38] By detailing prior hospital information (ie, discharge medications, prior presentations, tests completed), summaries could help prevent errors in medication dosing, reduce unnecessary testing, and help facilitate admission triage. Summaries may have information regarding a new diagnosis such as the results of an endoscopic evaluation that revealed the source of occult gastrointestinal bleeding, which could help contextualize a complaint of repeat melena and redirect goals of care. Discussions of goals of care in the discharge summary may guide primary providers in continued care management plans.

Our study findings underscore a positive correlation between late discharge summaries and readmissions. However, the extent that this is a causal relationship is unclear; the association of delay in days to complete the discharge summary with readmission may be an epiphenomenon related to processes related to quality of clinical care. For example, delays in discharge summary completion could be a marker of other system issues, such as a stressed work environment. It is possible that providers who fail to complete timely discharge summaries may also fail to do other important functions related to transitions of care and care coordination. However, even if this is so, timely discharge summaries could become a focal point for discussion for optimization of care transitions. A discharge summary could be delayed because the patient has already been readmitted before the summary was distributed, thus making that original summary less relevant. Delays could also be a reflection of the data complexity for patients with longer hospital stays. This is supported by the small but significant relationship between LOS and days to complete the discharge summary in this study. Lastly, delays in discharge summary completion may also be a proxy of provider communication and can reflect the culture of communication at the institution.

Although unplanned hospital readmission is an important outcome, many readmissions may be related to other factors such as disease progression, rather than late summaries or the lack of postdischarge communication. For instance, prior reports did not find any association between the PCP seeing the discharge summaries or direct communications with the PCP and 30‐day clinical outcomes for readmission and death.[26, 39] However, these studies were limited in their use of self‐reported handoffs, did not measure quality of information transfer, and failed to capture a broader audience beyond the PCP, such as ED physicians or specialists.

Our results suggest that the relationship between days to complete discharge summaries and 30‐day readmissions may vary depending on whether the hospitalization is primarily surgical/procedural versus medical treatment. A recent study found that most readmissions after surgery were associated with new complications related to the procedure and not exacerbation of prior index hospitalization complications.[40] Hence, treatment for common causes of hospital readmissions after surgical or gynecological procedures, such as wound infections, acute anemia, ileus, or dehydration, may not necessarily require a completed discharge summary for appropriate management. However, we caution extending this finding to clinical practice before further studies are conducted on specific procedures and in different clinical settings.

Results from this study also support institutional policies that specify the need for practitioners to complete discharge summaries contemporaneously, such as at the time of discharge or within a couple of days. Unlike other forms of communication that are optional, discharge summaries are required, so we recommend that practitioners be held accountable for short turnaround times. For example, providers could be graded and rated on timely completions of discharge summaries, among other performance variables. Anecdotally at our institutions, we have heard from practitioners that it takes less time to complete them when you do them on the day of discharge, because the hospitalization course is fresher in their mind and they have to wade through less information in the medical record to complete an accurate discharge summary. To this point, a barrier to on‐time completion is that providers may have misconceptions about what is really vital information to convey to the next provider. In agreement with past research and in the era of the electronic medical record system, we recommend that the discharge summary should be a quick synthesis of key findings that incorporates only the important elements, such as why the patient was hospitalized, what were key findings and key responses to therapy, what is pending at the time of discharge, what medications the patient is currently taking, and what are the follow‐up plans, rather than a lengthy expose of all the findings.[13, 36, 41, 42]

Lastly, our study results should be taken in the context of its limitations. As a single‐center study, findings may lack generalizability. In particular, the results may not generalize to hospitals that lack access to statewide reporting. We were also not able to assess readmission for patients who may have been readmitted to a hospital outside of Maryland. Although we adjusted for pertinent variables such as age, gender, healthcare payer, hospital service, comorbidity index, discharge location, LOS, and expected readmission rates, there may be other relevant confounders that we failed to capture or measure optimally. Median days to complete the discharge summary in this study was 8 days, which is longer than practices at other institutions, and may also limit this study's generalizability.[15, 36, 42] However, prior research supports our findings,[15] and a systematic review found that only 29% and 52% of discharge summaries were completed by 2 weeks and 4 weeks, respectively.[9] Finally, as noted above and perhaps most important, it is possible that discharge summary turnaround time does not in itself causally impact readmissions, but rather reflects an underlying commitment of the inpatient team to effectively coordinate care following hospital discharge.

CONCLUSION

In sum, this study delineates an underappreciated but important relationship of timely discharge summary completion and readmission outcomes. The discharge summary may be a relevant metric reflecting quality of patient care. Healthcare providers may begin to target timely discharge summaries as a potential focal point of quality‐improvement projects with the goal to facilitate better patient outcomes.