Statistical Analyses

Variation in hospitalist experience, reported practice, opinions, and knowledge regarding PICCs was assessed by hospitalist type (full time vs part time), years of practice (<1, 15, >5), and care‐delivery model (direct care vs learner‐based care). Bivariate comparisons were made using the ² or Fisher exact tests as appropriate; 2‐sided with a P value <0.05 was considered statistically significant. All analyses were conducted using Stata version 11 (StataCorp, College Station, TX). Local institutional review board approval was obtained at each site participating in the survey.

Hospitalist Experiences and Practice Related to Peripherally Inserted Central Catheters

According to responding hospitalists, the most common indications for PICC placement were long‐term IV antibiotic treatment (64%), followed by inability to obtain peripheral venous access (24%). Hospitalists reported an average duration of PICC placement of 17 days (range, 342 days). A significant percentage of hospitalists (93%) stated that they had cared for patients where a PICC was placed only for use during hospitalization, with the most common reason for such insertion being difficulty in otherwise securing venous access (67%). Respondents also reported caring for patients who had both PICCs and peripheral IV catheters in place at the same time; 49% stated that they had experienced this <5 times, whereas 33% stated they had experienced this 510 times. Furthermore, 87% of respondents indicated having admitted a patient who specifically requested a PICC due to prior difficulties with venous access. More than half of surveyed hospitalists (63%) admitted to having been contacted by a PICC nurse enquiring as to whether their patient might benefit from PICC insertion.

The majority of hospitalists (66%) reported that they specified the number of lumens when ordering PICCs. Thirty‐eight percent indicated that this decision was based on type of medication, whereas 35% selected the lowest number of lumens possible. A power PICC (specialized PICCs that are designed to withstand high‐pressure contrast injections), was specifically requested for radiographic studies (56%), infusion of large volume of fluids (10%), or was the default PICC type at their facility (34%).

A majority (74%) of survey respondents also reported that once inserted, PICCs were always used to obtain blood for routine laboratory testing. Moreover, 41% indicated that PICCs were also always used to obtain blood for microbiological cultures. The 3 most frequently encountered PICC‐related complications reported by hospitalists in our survey were blockage of a PICC lumen, bloodstream infection, and venous thromboembolism (VTE; Table 3).

Hospitalist Opinions Regarding Peripherally Inserted Central Catheters

Compared with CVCs, 69% of hospitalists felt that PICCs were safer and more efficient because they could stay in place longer and were less likely to cause infection. Most (65%) also agreed that PICCs were more convenient than CVCs because they were inserted by PICC teams. Additionally, 74% of hospitalists felt that their patients preferred PICCs because they minimize pain from routine peripheral IV changes and phlebotomy. A majority of respondents (84%) indicated that it was appropriate to place a PICC if other forms of peripheral venous access could not be obtained. However, when specifically questioned, 47% of hospitalists indicated that at least 10%25% of PICCs placed in their hospitals might represent inappropriate use. A majority (78%) agreed with the statement that the increase in numbers of vascular nurses had influenced use of PICCs in hospitalized patients, but most (45%) were neutral when asked if PICCs were more cost‐effective than traditional CVCs.

Hospitalist Knowledge Regarding Risk of Peripherally Inserted Central CatheterRelated Venous Thromboembolism and Bloodstream Infection

Although 65% of responding hospitalists disagreed with the statement that PICCs were less likely to lead to VTE, important knowledge gaps regarding PICCs and VTE were identified (Table 4). For instance, only 4% of hospitalists were correctly aware that the PICC‐tip position is checked to reduce risk of PICC‐related VTE, and only 12% knew that the site of PICC insertion has also been associated with VTE risk. Although 85% of respondents stated they would prescribe a therapeutic dose of an anticoagulant in the case of PICC‐associated VTE, deviations from the guideline‐recommended 3‐month treatment period were noted. For example, 6% of hospitalists reported treating with anticoagulation for 6 months, and 19% stated they would treat as long as the PICC remained in place, plus an additional period of time (eg, 24 weeks) after removal. With respect to bloodstream infection, 92% of responding hospitalists correctly identified PICC duration and prompt removal as factors promoting PICC‐related bloodstream infection and 78% accurately identified components of the catheter‐associated bloodstream infection bundle. When specifically asked about factors associated with risk of PICC‐related bloodstream infection, only half of respondents recognized the number of PICC lumens as being associated with this outcome.

Variation in Hospitalist Knowledge, Experience, or Opinions

We assessed whether any of our findings varied according to hospitalist type (full time versus part time), years of practice (<1, 15, >5), and model of care delivery (direct care vs learner‐based care). Our analyses suggested that part‐time hospitalists were more likely to select rarely when it came to finding patients with a PICC and a working peripheral IV at the same time (74% vs 45%, P=0.02). Interestingly, a higher percentage of those in practice <5 years indicated that 10%25% of PICCs represented inappropriate placement (58% vs 33%, P<0.01) and that vascular nurses had influenced the use of PICCs in hospitalized patients (88% vs 69%, P=0.01). Lastly, a higher percentage of hospitalists who provided direct patient care reported that PICCs were always used to obtain blood for microbiological culture (54% vs 37%, P=0.05).

Statistical Analyses

Variation in hospitalist experience, reported practice, opinions, and knowledge regarding PICCs was assessed by hospitalist type (full time vs part time), years of practice (<1, 15, >5), and care‐delivery model (direct care vs learner‐based care). Bivariate comparisons were made using the ² or Fisher exact tests as appropriate; 2‐sided with a P value <0.05 was considered statistically significant. All analyses were conducted using Stata version 11 (StataCorp, College Station, TX). Local institutional review board approval was obtained at each site participating in the survey.

Hospitalist Experiences and Practice Related to Peripherally Inserted Central Catheters

According to responding hospitalists, the most common indications for PICC placement were long‐term IV antibiotic treatment (64%), followed by inability to obtain peripheral venous access (24%). Hospitalists reported an average duration of PICC placement of 17 days (range, 342 days). A significant percentage of hospitalists (93%) stated that they had cared for patients where a PICC was placed only for use during hospitalization, with the most common reason for such insertion being difficulty in otherwise securing venous access (67%). Respondents also reported caring for patients who had both PICCs and peripheral IV catheters in place at the same time; 49% stated that they had experienced this <5 times, whereas 33% stated they had experienced this 510 times. Furthermore, 87% of respondents indicated having admitted a patient who specifically requested a PICC due to prior difficulties with venous access. More than half of surveyed hospitalists (63%) admitted to having been contacted by a PICC nurse enquiring as to whether their patient might benefit from PICC insertion.

The majority of hospitalists (66%) reported that they specified the number of lumens when ordering PICCs. Thirty‐eight percent indicated that this decision was based on type of medication, whereas 35% selected the lowest number of lumens possible. A power PICC (specialized PICCs that are designed to withstand high‐pressure contrast injections), was specifically requested for radiographic studies (56%), infusion of large volume of fluids (10%), or was the default PICC type at their facility (34%).

A majority (74%) of survey respondents also reported that once inserted, PICCs were always used to obtain blood for routine laboratory testing. Moreover, 41% indicated that PICCs were also always used to obtain blood for microbiological cultures. The 3 most frequently encountered PICC‐related complications reported by hospitalists in our survey were blockage of a PICC lumen, bloodstream infection, and venous thromboembolism (VTE; Table 3).

Hospitalist Opinions Regarding Peripherally Inserted Central Catheters

Compared with CVCs, 69% of hospitalists felt that PICCs were safer and more efficient because they could stay in place longer and were less likely to cause infection. Most (65%) also agreed that PICCs were more convenient than CVCs because they were inserted by PICC teams. Additionally, 74% of hospitalists felt that their patients preferred PICCs because they minimize pain from routine peripheral IV changes and phlebotomy. A majority of respondents (84%) indicated that it was appropriate to place a PICC if other forms of peripheral venous access could not be obtained. However, when specifically questioned, 47% of hospitalists indicated that at least 10%25% of PICCs placed in their hospitals might represent inappropriate use. A majority (78%) agreed with the statement that the increase in numbers of vascular nurses had influenced use of PICCs in hospitalized patients, but most (45%) were neutral when asked if PICCs were more cost‐effective than traditional CVCs.

Hospitalist Knowledge Regarding Risk of Peripherally Inserted Central CatheterRelated Venous Thromboembolism and Bloodstream Infection

Although 65% of responding hospitalists disagreed with the statement that PICCs were less likely to lead to VTE, important knowledge gaps regarding PICCs and VTE were identified (Table 4). For instance, only 4% of hospitalists were correctly aware that the PICC‐tip position is checked to reduce risk of PICC‐related VTE, and only 12% knew that the site of PICC insertion has also been associated with VTE risk. Although 85% of respondents stated they would prescribe a therapeutic dose of an anticoagulant in the case of PICC‐associated VTE, deviations from the guideline‐recommended 3‐month treatment period were noted. For example, 6% of hospitalists reported treating with anticoagulation for 6 months, and 19% stated they would treat as long as the PICC remained in place, plus an additional period of time (eg, 24 weeks) after removal. With respect to bloodstream infection, 92% of responding hospitalists correctly identified PICC duration and prompt removal as factors promoting PICC‐related bloodstream infection and 78% accurately identified components of the catheter‐associated bloodstream infection bundle. When specifically asked about factors associated with risk of PICC‐related bloodstream infection, only half of respondents recognized the number of PICC lumens as being associated with this outcome.

Variation in Hospitalist Knowledge, Experience, or Opinions

We assessed whether any of our findings varied according to hospitalist type (full time versus part time), years of practice (<1, 15, >5), and model of care delivery (direct care vs learner‐based care). Our analyses suggested that part‐time hospitalists were more likely to select rarely when it came to finding patients with a PICC and a working peripheral IV at the same time (74% vs 45%, P=0.02). Interestingly, a higher percentage of those in practice <5 years indicated that 10%25% of PICCs represented inappropriate placement (58% vs 33%, P<0.01) and that vascular nurses had influenced the use of PICCs in hospitalized patients (88% vs 69%, P=0.01). Lastly, a higher percentage of hospitalists who provided direct patient care reported that PICCs were always used to obtain blood for microbiological culture (54% vs 37%, P=0.05).

Statistical Analyses

Variation in hospitalist experience, reported practice, opinions, and knowledge regarding PICCs was assessed by hospitalist type (full time vs part time), years of practice (<1, 15, >5), and care‐delivery model (direct care vs learner‐based care). Bivariate comparisons were made using the ² or Fisher exact tests as appropriate; 2‐sided with a P value <0.05 was considered statistically significant. All analyses were conducted using Stata version 11 (StataCorp, College Station, TX). Local institutional review board approval was obtained at each site participating in the survey.

Hospitalist Experiences and Practice Related to Peripherally Inserted Central Catheters

According to responding hospitalists, the most common indications for PICC placement were long‐term IV antibiotic treatment (64%), followed by inability to obtain peripheral venous access (24%). Hospitalists reported an average duration of PICC placement of 17 days (range, 342 days). A significant percentage of hospitalists (93%) stated that they had cared for patients where a PICC was placed only for use during hospitalization, with the most common reason for such insertion being difficulty in otherwise securing venous access (67%). Respondents also reported caring for patients who had both PICCs and peripheral IV catheters in place at the same time; 49% stated that they had experienced this <5 times, whereas 33% stated they had experienced this 510 times. Furthermore, 87% of respondents indicated having admitted a patient who specifically requested a PICC due to prior difficulties with venous access. More than half of surveyed hospitalists (63%) admitted to having been contacted by a PICC nurse enquiring as to whether their patient might benefit from PICC insertion.

The majority of hospitalists (66%) reported that they specified the number of lumens when ordering PICCs. Thirty‐eight percent indicated that this decision was based on type of medication, whereas 35% selected the lowest number of lumens possible. A power PICC (specialized PICCs that are designed to withstand high‐pressure contrast injections), was specifically requested for radiographic studies (56%), infusion of large volume of fluids (10%), or was the default PICC type at their facility (34%).

A majority (74%) of survey respondents also reported that once inserted, PICCs were always used to obtain blood for routine laboratory testing. Moreover, 41% indicated that PICCs were also always used to obtain blood for microbiological cultures. The 3 most frequently encountered PICC‐related complications reported by hospitalists in our survey were blockage of a PICC lumen, bloodstream infection, and venous thromboembolism (VTE; Table 3).

Hospitalist Opinions Regarding Peripherally Inserted Central Catheters

Compared with CVCs, 69% of hospitalists felt that PICCs were safer and more efficient because they could stay in place longer and were less likely to cause infection. Most (65%) also agreed that PICCs were more convenient than CVCs because they were inserted by PICC teams. Additionally, 74% of hospitalists felt that their patients preferred PICCs because they minimize pain from routine peripheral IV changes and phlebotomy. A majority of respondents (84%) indicated that it was appropriate to place a PICC if other forms of peripheral venous access could not be obtained. However, when specifically questioned, 47% of hospitalists indicated that at least 10%25% of PICCs placed in their hospitals might represent inappropriate use. A majority (78%) agreed with the statement that the increase in numbers of vascular nurses had influenced use of PICCs in hospitalized patients, but most (45%) were neutral when asked if PICCs were more cost‐effective than traditional CVCs.

Hospitalist Knowledge Regarding Risk of Peripherally Inserted Central CatheterRelated Venous Thromboembolism and Bloodstream Infection

Although 65% of responding hospitalists disagreed with the statement that PICCs were less likely to lead to VTE, important knowledge gaps regarding PICCs and VTE were identified (Table 4). For instance, only 4% of hospitalists were correctly aware that the PICC‐tip position is checked to reduce risk of PICC‐related VTE, and only 12% knew that the site of PICC insertion has also been associated with VTE risk. Although 85% of respondents stated they would prescribe a therapeutic dose of an anticoagulant in the case of PICC‐associated VTE, deviations from the guideline‐recommended 3‐month treatment period were noted. For example, 6% of hospitalists reported treating with anticoagulation for 6 months, and 19% stated they would treat as long as the PICC remained in place, plus an additional period of time (eg, 24 weeks) after removal. With respect to bloodstream infection, 92% of responding hospitalists correctly identified PICC duration and prompt removal as factors promoting PICC‐related bloodstream infection and 78% accurately identified components of the catheter‐associated bloodstream infection bundle. When specifically asked about factors associated with risk of PICC‐related bloodstream infection, only half of respondents recognized the number of PICC lumens as being associated with this outcome.

Variation in Hospitalist Knowledge, Experience, or Opinions

We assessed whether any of our findings varied according to hospitalist type (full time versus part time), years of practice (<1, 15, >5), and model of care delivery (direct care vs learner‐based care). Our analyses suggested that part‐time hospitalists were more likely to select rarely when it came to finding patients with a PICC and a working peripheral IV at the same time (74% vs 45%, P=0.02). Interestingly, a higher percentage of those in practice <5 years indicated that 10%25% of PICCs represented inappropriate placement (58% vs 33%, P<0.01) and that vascular nurses had influenced the use of PICCs in hospitalized patients (88% vs 69%, P=0.01). Lastly, a higher percentage of hospitalists who provided direct patient care reported that PICCs were always used to obtain blood for microbiological culture (54% vs 37%, P=0.05).

Design

This was a retrospective cross‐sectional study at a single tertiary‐care academic medical center describing the incidence of ChEI initiation. Patient data were obtained from electronic medical records at The Methodist Hospital (TMH) and from the University HealthSystem Consortium Clinical Data Base/Resource Manager (UHC CDB/RM; http://www.uhc.edu). The institutional review board at TMH Research Institute (Houston, TX) approved this study with a waiver of informed consent.

Inclusion Criteria

All patients admitted to TMH from September 6, 2010, through March 31, 2011, and who were dispensed a ChEI (defined as donepezil, galantamine, and rivastigmine) were included. The study start date (September 6, 2010) coincided with adoption of a new feature in the electronic medical record that allowed for improved tracking of patient home medications before admission.

Exclusion Criteria

Patients were excluded if they were age <18 years or if information for the index admission was not available in the UHC CDB/RM.

Data Variables

The first hospitalization during the study period where a ChEI was dispensed was considered the index admission, and all data are based on this index admission. Investigators used a database of home medications, history and physical notes, and daily progress notes contained in the electronic medication record to categorize patients into 1 of 2 groups: (1) initiation of ChEI therapy and (2) continuation of ChEI therapy. Investigators reviewed all daily progress notes and consult notes that were documented for the index admission and all admissions in the 60 days prior to the index admission to elicit information regarding previous ChEI exposure. A clinical pharmacist performed a medication‐history interview of all patients admitted through the emergency department. This reconciliation process was supported with 4 months of prescription‐medication claim history from insurance companies and pharmacies that participate in the Health Care Systems Medication Reconciliation report (Health Care Systems, Inc., Montgomery, AL). Patients directly admitted to the hospital received medication reconciliation from a clinical pharmacist, physician, or nurse.

If documentation was found indicating ChEI exposure within 60 days prior to the index admission, the patient was categorized as continuation of ChEI therapy. If there was no prior documentation of ChEI therapy, or if there was clear documentation of ChEI initiation for a new diagnosis, the patient was categorized as initiation of ChEI therapy. To improve accuracy, 2 investigators (K.C.W. and N.T.‐M.) categorized patients independently, and a third investigator (J.T.S.) settled all discrepancies.

The UHC CDB/RM provided patient admission severity of illness (mild, moderate, major, and extreme) generated from 3M All Patient Refined Diagnosis Related Groups software (APR‐DRG; 3M Health Information Systems, Salt Lake City, UT), which accounts for 29 comorbidities that are correlated with resource utilization and severity of illness.[14]

Data Analysis

Mean with standard deviation was used for continuous data with a normal distribution. Median with interquartile range (IQR) was used for ordinal data or continuous data that did not have a normal distribution. Data were tested for normality using the Anderson‐Darling Normality Test, with a P value of <0.05 signifying nonparametric data. In‐hospital mortality was compared using 2 2 contingency tables and the Fisher exact test or ² test. Hospital LOS and ICU LOS were compared using a Mann‐Whitney U test. To estimate the crude association between each factor and LOS, univariate linear regression analysis was conducted for each predictor variable. The following variables were considered as possible predictors: categorization as ChEI initiation or ChEI continuation, age, admission severity of illness, and admission risk of mortality. Variables that had a P value <0.20 in the univariate linear regression analysis were entered into a multivariate model. Statistics were performed using GraphPad Prism, version 5 (GraphPad Software, Inc., La Jolla, CA), and Minitab, version 16 (Minitab, Inc., State College, PA). An value of 0.05 was set for statistical significance.

Demographic Data

During the 7‐month study period, there were 20,516 adult admissions to TMH. Four hundred seventy‐six patients were admitted to TMH, dispensed a ChEI, and met our inclusion criteria. Of these 476 patients, 434 (91%) were continued on ChEI therapy that was started prior to hospital admission and 42 (9%) were initiated on ChEI therapy in the inpatient setting. Four patients who otherwise met inclusion criteria were excluded because their information was not available in the UHC CDB/RM. The prevalence of ChEI exposure and incidence of new ChEI initiation was 23.2 (95% confidence interval [CI]: 21.225.4) and 2 (95% CI: 1.5‐2.8) per 1000 adult admissions, respectively. Patients exposed to ChEI therapy were geriatric (median age, 82 years; IQR, 7687), predominantly white (64%), and predominately female (60%). Baseline characteristics were similar between patients who initiated ChEI therapy and patients who continued ChEI therapy in regard to age, sex, race, and admission severity of illness (Table 1). Based on Major Diagnostic Categories (MDC) for admission APR‐DRG, 52% (22 of 42) of the ChEI initiation group were admitted for a disease that was not mental health related or neurological in nature.

Cholinesterase Inhibitor Selection

Donepezil (78%) was the most frequently prescribed ChEI in both study groups, followed by rivastigmine (17%) and galantamine (5%). No patients in the ChEI initiation group received galantamine. All patients in the continuation group were continued on the same ChEI agent as an inpatient, except for 1 patient admitted on donepezil who was switched to rivastigmine and 1 patient admitted on rivastigmine who had donepezil added.

Cholinesterase Inhibitor Initiation and Course of Therapy

Detailed characteristics of the 42 patients who were initiated on ChEI as inpatients are listed in Table 2. The most common presumed indication for initiation of ChEI was unclassified dementia (62%), followed by Alzheimer disease (12%) and mixed dementia (12%). The most common physician service lines that ordered the ChEI were neurology (57%), internal medicine (12%), and geriatrics (10%). Patients were hospitalized for a median of 2 days before initiation of ChEI and were exposed to therapy for a median of 3 days. Of patients discharged from the hospital, 90% (37 of 41) had orders to continue the ChEI postdischarge. Cholinesterase Inhibitor therapy was initiated within 48 hours of discharge and continued through discharge in 10 (24%) of patients.

Antipsychotic and benzodiazepine therapy was initiated (no documented use before admission) in 33% (14 of 42) and 31% (13 of 42) of admissions, respectively. Both antipsychotic therapy and benzodiazepine therapy were initiated in 17% (7 of 42). The incidence of infection that was treated with antibiotic therapy was 48% (20 of 42).

Only 2 patients (5%) were initiated on ChEI while admitted to an ICU. Both of these patients were screened with the Confusion Assessment Method for the ICU (CAM‐ICU) and tested positive for delirium.[15] One of these 2 patients accounted for the only mortality that occurred in the group of 42 patients who were initiated on ChEI. This patient was started on donepezil in the medical ICU on hospital day 4 and continued on therapy for 14 days until death. During this hospital stay, the patient was also initiated on both haloperidol and lorazepam and received antibiotics for pneumonia. A detailed description of the other patient is listed under patient 3 in Appendix 1 (see Supporting Information, Appendix 1, in the online version of this article).

Sensitivity Analysis

To minimize the impact of incomplete documentation of a previous ChEI exposure, a sensitivity analysis was conducted that excluded all patients who received an order for ChEI within 24 hours of admission from the ChEI initiation group (9 of 42). In this analysis, the incidence of ChEI initiation was 7% (33 of 476) and the proportion of adult admissions with ChEI initiation was 1.6 (95% CI: 1.1‐2.3) per 1000 admissions. The incidences of infection (52%), initiation of antipsychotics (33%), and initiation of benzodiazepines (31%) were similar to the original ChEI initiation group. The median LOS before ChEI initiation was 3 days (IQR, 24.5). The median hospital LOS was 7 days (IQR, 4.59.5). Ninety percent of patients were discharged home on ChEI therapy. Eighteen percent were readmitted within 30 days.

Outcome Data

In‐hospital mortality was low (2.5%,12 of 476) in this patient cohort, with no observed difference between patients initiated on ChEI therapy (2%, 1 of 42) and patients continued on ChEI therapy (3%, 11 of 434). The rate of 30‐day readmission was 15% (6 of 41) for patients initiating ChEI therapy and 13% (56 of 423) for patients continuing ChEI therapy. Hospital LOS was 1.5 days longer in patients initiated on ChEI (median, 6.5 days for initiation vs 5 days for continuation, P=0.0147). Patients who initiated ChEI therapy experienced a 32% increase in hospital LOS compared with patients who continued ChEI therapy in a multivariate linear regression analysis that accounted for admission severity of illness and admission risk of mortality (P=0.007). Rates of ICU admission were low (24%, 115 of 476) and there was no observed difference between groups (14% [6 of 42] for initiation vs 25% [109 of 434] for continuation, P=0.117).

Eleven of the 12 deaths were in patients who were treated with donepezil; however, there was no observed difference in the incidence of mortality for patients treated with donepezil vs patients treated with either rivastigmine or galantamine (3% vs 1%, P=0.479).

Limitations

The major limitation to this study is that the true incidence of delirium in this population is unknown. Unfortunately, acute care patients admitted to our hospital during this study period were not consistently screened for delirium using a validated screening tool. A previous study found that clinicians are unable to diagnose 70% of cases of delirium when a validated delirium screening tool is not used.[18] Therefore, we did not attempt to quantify the incidence of delirium using progress notes or diagnosis codes, as this incidence would be falsely low and unreliable. Our hospital is currently improving the culture of awareness of delirium, and efforts are being made to establish and improve routine screening for delirium in both the acute care and critical care setting.

There were limitations to the outcomes of mortality, readmission, and hospital LOS that were reported. Reported in‐hospital mortality did not account for patients who were transferred for hospice care or patients who were transferred to another facility and subsequently died. Only hospitalizations to TMH were counted for 30‐day readmission rates; admissions to another hospital were unknown. The sample size was too small to estimate the effects of ChEI initiation on 30‐day readmission rates and in‐hospital mortality. Physicians may have been more likely to prescribe ChEI therapy in patients who had prolonged hospital LOS, and the prolonged LOS observed in the ChEI‐initiation group may be confounded by selection bias.

Design

This was a retrospective cross‐sectional study at a single tertiary‐care academic medical center describing the incidence of ChEI initiation. Patient data were obtained from electronic medical records at The Methodist Hospital (TMH) and from the University HealthSystem Consortium Clinical Data Base/Resource Manager (UHC CDB/RM; http://www.uhc.edu). The institutional review board at TMH Research Institute (Houston, TX) approved this study with a waiver of informed consent.

Inclusion Criteria

All patients admitted to TMH from September 6, 2010, through March 31, 2011, and who were dispensed a ChEI (defined as donepezil, galantamine, and rivastigmine) were included. The study start date (September 6, 2010) coincided with adoption of a new feature in the electronic medical record that allowed for improved tracking of patient home medications before admission.

Exclusion Criteria

Patients were excluded if they were age <18 years or if information for the index admission was not available in the UHC CDB/RM.

Data Variables

The first hospitalization during the study period where a ChEI was dispensed was considered the index admission, and all data are based on this index admission. Investigators used a database of home medications, history and physical notes, and daily progress notes contained in the electronic medication record to categorize patients into 1 of 2 groups: (1) initiation of ChEI therapy and (2) continuation of ChEI therapy. Investigators reviewed all daily progress notes and consult notes that were documented for the index admission and all admissions in the 60 days prior to the index admission to elicit information regarding previous ChEI exposure. A clinical pharmacist performed a medication‐history interview of all patients admitted through the emergency department. This reconciliation process was supported with 4 months of prescription‐medication claim history from insurance companies and pharmacies that participate in the Health Care Systems Medication Reconciliation report (Health Care Systems, Inc., Montgomery, AL). Patients directly admitted to the hospital received medication reconciliation from a clinical pharmacist, physician, or nurse.

If documentation was found indicating ChEI exposure within 60 days prior to the index admission, the patient was categorized as continuation of ChEI therapy. If there was no prior documentation of ChEI therapy, or if there was clear documentation of ChEI initiation for a new diagnosis, the patient was categorized as initiation of ChEI therapy. To improve accuracy, 2 investigators (K.C.W. and N.T.‐M.) categorized patients independently, and a third investigator (J.T.S.) settled all discrepancies.

The UHC CDB/RM provided patient admission severity of illness (mild, moderate, major, and extreme) generated from 3M All Patient Refined Diagnosis Related Groups software (APR‐DRG; 3M Health Information Systems, Salt Lake City, UT), which accounts for 29 comorbidities that are correlated with resource utilization and severity of illness.[14]

Data Analysis

Mean with standard deviation was used for continuous data with a normal distribution. Median with interquartile range (IQR) was used for ordinal data or continuous data that did not have a normal distribution. Data were tested for normality using the Anderson‐Darling Normality Test, with a P value of <0.05 signifying nonparametric data. In‐hospital mortality was compared using 2 2 contingency tables and the Fisher exact test or ² test. Hospital LOS and ICU LOS were compared using a Mann‐Whitney U test. To estimate the crude association between each factor and LOS, univariate linear regression analysis was conducted for each predictor variable. The following variables were considered as possible predictors: categorization as ChEI initiation or ChEI continuation, age, admission severity of illness, and admission risk of mortality. Variables that had a P value <0.20 in the univariate linear regression analysis were entered into a multivariate model. Statistics were performed using GraphPad Prism, version 5 (GraphPad Software, Inc., La Jolla, CA), and Minitab, version 16 (Minitab, Inc., State College, PA). An value of 0.05 was set for statistical significance.

Demographic Data

During the 7‐month study period, there were 20,516 adult admissions to TMH. Four hundred seventy‐six patients were admitted to TMH, dispensed a ChEI, and met our inclusion criteria. Of these 476 patients, 434 (91%) were continued on ChEI therapy that was started prior to hospital admission and 42 (9%) were initiated on ChEI therapy in the inpatient setting. Four patients who otherwise met inclusion criteria were excluded because their information was not available in the UHC CDB/RM. The prevalence of ChEI exposure and incidence of new ChEI initiation was 23.2 (95% confidence interval [CI]: 21.225.4) and 2 (95% CI: 1.5‐2.8) per 1000 adult admissions, respectively. Patients exposed to ChEI therapy were geriatric (median age, 82 years; IQR, 7687), predominantly white (64%), and predominately female (60%). Baseline characteristics were similar between patients who initiated ChEI therapy and patients who continued ChEI therapy in regard to age, sex, race, and admission severity of illness (Table 1). Based on Major Diagnostic Categories (MDC) for admission APR‐DRG, 52% (22 of 42) of the ChEI initiation group were admitted for a disease that was not mental health related or neurological in nature.

Cholinesterase Inhibitor Selection

Donepezil (78%) was the most frequently prescribed ChEI in both study groups, followed by rivastigmine (17%) and galantamine (5%). No patients in the ChEI initiation group received galantamine. All patients in the continuation group were continued on the same ChEI agent as an inpatient, except for 1 patient admitted on donepezil who was switched to rivastigmine and 1 patient admitted on rivastigmine who had donepezil added.

Cholinesterase Inhibitor Initiation and Course of Therapy

Detailed characteristics of the 42 patients who were initiated on ChEI as inpatients are listed in Table 2. The most common presumed indication for initiation of ChEI was unclassified dementia (62%), followed by Alzheimer disease (12%) and mixed dementia (12%). The most common physician service lines that ordered the ChEI were neurology (57%), internal medicine (12%), and geriatrics (10%). Patients were hospitalized for a median of 2 days before initiation of ChEI and were exposed to therapy for a median of 3 days. Of patients discharged from the hospital, 90% (37 of 41) had orders to continue the ChEI postdischarge. Cholinesterase Inhibitor therapy was initiated within 48 hours of discharge and continued through discharge in 10 (24%) of patients.

Antipsychotic and benzodiazepine therapy was initiated (no documented use before admission) in 33% (14 of 42) and 31% (13 of 42) of admissions, respectively. Both antipsychotic therapy and benzodiazepine therapy were initiated in 17% (7 of 42). The incidence of infection that was treated with antibiotic therapy was 48% (20 of 42).

Only 2 patients (5%) were initiated on ChEI while admitted to an ICU. Both of these patients were screened with the Confusion Assessment Method for the ICU (CAM‐ICU) and tested positive for delirium.[15] One of these 2 patients accounted for the only mortality that occurred in the group of 42 patients who were initiated on ChEI. This patient was started on donepezil in the medical ICU on hospital day 4 and continued on therapy for 14 days until death. During this hospital stay, the patient was also initiated on both haloperidol and lorazepam and received antibiotics for pneumonia. A detailed description of the other patient is listed under patient 3 in Appendix 1 (see Supporting Information, Appendix 1, in the online version of this article).

Sensitivity Analysis

To minimize the impact of incomplete documentation of a previous ChEI exposure, a sensitivity analysis was conducted that excluded all patients who received an order for ChEI within 24 hours of admission from the ChEI initiation group (9 of 42). In this analysis, the incidence of ChEI initiation was 7% (33 of 476) and the proportion of adult admissions with ChEI initiation was 1.6 (95% CI: 1.1‐2.3) per 1000 admissions. The incidences of infection (52%), initiation of antipsychotics (33%), and initiation of benzodiazepines (31%) were similar to the original ChEI initiation group. The median LOS before ChEI initiation was 3 days (IQR, 24.5). The median hospital LOS was 7 days (IQR, 4.59.5). Ninety percent of patients were discharged home on ChEI therapy. Eighteen percent were readmitted within 30 days.

Outcome Data

In‐hospital mortality was low (2.5%,12 of 476) in this patient cohort, with no observed difference between patients initiated on ChEI therapy (2%, 1 of 42) and patients continued on ChEI therapy (3%, 11 of 434). The rate of 30‐day readmission was 15% (6 of 41) for patients initiating ChEI therapy and 13% (56 of 423) for patients continuing ChEI therapy. Hospital LOS was 1.5 days longer in patients initiated on ChEI (median, 6.5 days for initiation vs 5 days for continuation, P=0.0147). Patients who initiated ChEI therapy experienced a 32% increase in hospital LOS compared with patients who continued ChEI therapy in a multivariate linear regression analysis that accounted for admission severity of illness and admission risk of mortality (P=0.007). Rates of ICU admission were low (24%, 115 of 476) and there was no observed difference between groups (14% [6 of 42] for initiation vs 25% [109 of 434] for continuation, P=0.117).

Eleven of the 12 deaths were in patients who were treated with donepezil; however, there was no observed difference in the incidence of mortality for patients treated with donepezil vs patients treated with either rivastigmine or galantamine (3% vs 1%, P=0.479).

Limitations

The major limitation to this study is that the true incidence of delirium in this population is unknown. Unfortunately, acute care patients admitted to our hospital during this study period were not consistently screened for delirium using a validated screening tool. A previous study found that clinicians are unable to diagnose 70% of cases of delirium when a validated delirium screening tool is not used.[18] Therefore, we did not attempt to quantify the incidence of delirium using progress notes or diagnosis codes, as this incidence would be falsely low and unreliable. Our hospital is currently improving the culture of awareness of delirium, and efforts are being made to establish and improve routine screening for delirium in both the acute care and critical care setting.

There were limitations to the outcomes of mortality, readmission, and hospital LOS that were reported. Reported in‐hospital mortality did not account for patients who were transferred for hospice care or patients who were transferred to another facility and subsequently died. Only hospitalizations to TMH were counted for 30‐day readmission rates; admissions to another hospital were unknown. The sample size was too small to estimate the effects of ChEI initiation on 30‐day readmission rates and in‐hospital mortality. Physicians may have been more likely to prescribe ChEI therapy in patients who had prolonged hospital LOS, and the prolonged LOS observed in the ChEI‐initiation group may be confounded by selection bias.

Design

This was a retrospective cross‐sectional study at a single tertiary‐care academic medical center describing the incidence of ChEI initiation. Patient data were obtained from electronic medical records at The Methodist Hospital (TMH) and from the University HealthSystem Consortium Clinical Data Base/Resource Manager (UHC CDB/RM; http://www.uhc.edu). The institutional review board at TMH Research Institute (Houston, TX) approved this study with a waiver of informed consent.

Inclusion Criteria

All patients admitted to TMH from September 6, 2010, through March 31, 2011, and who were dispensed a ChEI (defined as donepezil, galantamine, and rivastigmine) were included. The study start date (September 6, 2010) coincided with adoption of a new feature in the electronic medical record that allowed for improved tracking of patient home medications before admission.

Exclusion Criteria

Patients were excluded if they were age <18 years or if information for the index admission was not available in the UHC CDB/RM.

Data Variables

The first hospitalization during the study period where a ChEI was dispensed was considered the index admission, and all data are based on this index admission. Investigators used a database of home medications, history and physical notes, and daily progress notes contained in the electronic medication record to categorize patients into 1 of 2 groups: (1) initiation of ChEI therapy and (2) continuation of ChEI therapy. Investigators reviewed all daily progress notes and consult notes that were documented for the index admission and all admissions in the 60 days prior to the index admission to elicit information regarding previous ChEI exposure. A clinical pharmacist performed a medication‐history interview of all patients admitted through the emergency department. This reconciliation process was supported with 4 months of prescription‐medication claim history from insurance companies and pharmacies that participate in the Health Care Systems Medication Reconciliation report (Health Care Systems, Inc., Montgomery, AL). Patients directly admitted to the hospital received medication reconciliation from a clinical pharmacist, physician, or nurse.

If documentation was found indicating ChEI exposure within 60 days prior to the index admission, the patient was categorized as continuation of ChEI therapy. If there was no prior documentation of ChEI therapy, or if there was clear documentation of ChEI initiation for a new diagnosis, the patient was categorized as initiation of ChEI therapy. To improve accuracy, 2 investigators (K.C.W. and N.T.‐M.) categorized patients independently, and a third investigator (J.T.S.) settled all discrepancies.

The UHC CDB/RM provided patient admission severity of illness (mild, moderate, major, and extreme) generated from 3M All Patient Refined Diagnosis Related Groups software (APR‐DRG; 3M Health Information Systems, Salt Lake City, UT), which accounts for 29 comorbidities that are correlated with resource utilization and severity of illness.[14]

Data Analysis

Mean with standard deviation was used for continuous data with a normal distribution. Median with interquartile range (IQR) was used for ordinal data or continuous data that did not have a normal distribution. Data were tested for normality using the Anderson‐Darling Normality Test, with a P value of <0.05 signifying nonparametric data. In‐hospital mortality was compared using 2 2 contingency tables and the Fisher exact test or ² test. Hospital LOS and ICU LOS were compared using a Mann‐Whitney U test. To estimate the crude association between each factor and LOS, univariate linear regression analysis was conducted for each predictor variable. The following variables were considered as possible predictors: categorization as ChEI initiation or ChEI continuation, age, admission severity of illness, and admission risk of mortality. Variables that had a P value <0.20 in the univariate linear regression analysis were entered into a multivariate model. Statistics were performed using GraphPad Prism, version 5 (GraphPad Software, Inc., La Jolla, CA), and Minitab, version 16 (Minitab, Inc., State College, PA). An value of 0.05 was set for statistical significance.

Demographic Data

During the 7‐month study period, there were 20,516 adult admissions to TMH. Four hundred seventy‐six patients were admitted to TMH, dispensed a ChEI, and met our inclusion criteria. Of these 476 patients, 434 (91%) were continued on ChEI therapy that was started prior to hospital admission and 42 (9%) were initiated on ChEI therapy in the inpatient setting. Four patients who otherwise met inclusion criteria were excluded because their information was not available in the UHC CDB/RM. The prevalence of ChEI exposure and incidence of new ChEI initiation was 23.2 (95% confidence interval [CI]: 21.225.4) and 2 (95% CI: 1.5‐2.8) per 1000 adult admissions, respectively. Patients exposed to ChEI therapy were geriatric (median age, 82 years; IQR, 7687), predominantly white (64%), and predominately female (60%). Baseline characteristics were similar between patients who initiated ChEI therapy and patients who continued ChEI therapy in regard to age, sex, race, and admission severity of illness (Table 1). Based on Major Diagnostic Categories (MDC) for admission APR‐DRG, 52% (22 of 42) of the ChEI initiation group were admitted for a disease that was not mental health related or neurological in nature.

Cholinesterase Inhibitor Selection

Donepezil (78%) was the most frequently prescribed ChEI in both study groups, followed by rivastigmine (17%) and galantamine (5%). No patients in the ChEI initiation group received galantamine. All patients in the continuation group were continued on the same ChEI agent as an inpatient, except for 1 patient admitted on donepezil who was switched to rivastigmine and 1 patient admitted on rivastigmine who had donepezil added.

Cholinesterase Inhibitor Initiation and Course of Therapy

Detailed characteristics of the 42 patients who were initiated on ChEI as inpatients are listed in Table 2. The most common presumed indication for initiation of ChEI was unclassified dementia (62%), followed by Alzheimer disease (12%) and mixed dementia (12%). The most common physician service lines that ordered the ChEI were neurology (57%), internal medicine (12%), and geriatrics (10%). Patients were hospitalized for a median of 2 days before initiation of ChEI and were exposed to therapy for a median of 3 days. Of patients discharged from the hospital, 90% (37 of 41) had orders to continue the ChEI postdischarge. Cholinesterase Inhibitor therapy was initiated within 48 hours of discharge and continued through discharge in 10 (24%) of patients.

Antipsychotic and benzodiazepine therapy was initiated (no documented use before admission) in 33% (14 of 42) and 31% (13 of 42) of admissions, respectively. Both antipsychotic therapy and benzodiazepine therapy were initiated in 17% (7 of 42). The incidence of infection that was treated with antibiotic therapy was 48% (20 of 42).

Only 2 patients (5%) were initiated on ChEI while admitted to an ICU. Both of these patients were screened with the Confusion Assessment Method for the ICU (CAM‐ICU) and tested positive for delirium.[15] One of these 2 patients accounted for the only mortality that occurred in the group of 42 patients who were initiated on ChEI. This patient was started on donepezil in the medical ICU on hospital day 4 and continued on therapy for 14 days until death. During this hospital stay, the patient was also initiated on both haloperidol and lorazepam and received antibiotics for pneumonia. A detailed description of the other patient is listed under patient 3 in Appendix 1 (see Supporting Information, Appendix 1, in the online version of this article).

Sensitivity Analysis

To minimize the impact of incomplete documentation of a previous ChEI exposure, a sensitivity analysis was conducted that excluded all patients who received an order for ChEI within 24 hours of admission from the ChEI initiation group (9 of 42). In this analysis, the incidence of ChEI initiation was 7% (33 of 476) and the proportion of adult admissions with ChEI initiation was 1.6 (95% CI: 1.1‐2.3) per 1000 admissions. The incidences of infection (52%), initiation of antipsychotics (33%), and initiation of benzodiazepines (31%) were similar to the original ChEI initiation group. The median LOS before ChEI initiation was 3 days (IQR, 24.5). The median hospital LOS was 7 days (IQR, 4.59.5). Ninety percent of patients were discharged home on ChEI therapy. Eighteen percent were readmitted within 30 days.

Outcome Data

In‐hospital mortality was low (2.5%,12 of 476) in this patient cohort, with no observed difference between patients initiated on ChEI therapy (2%, 1 of 42) and patients continued on ChEI therapy (3%, 11 of 434). The rate of 30‐day readmission was 15% (6 of 41) for patients initiating ChEI therapy and 13% (56 of 423) for patients continuing ChEI therapy. Hospital LOS was 1.5 days longer in patients initiated on ChEI (median, 6.5 days for initiation vs 5 days for continuation, P=0.0147). Patients who initiated ChEI therapy experienced a 32% increase in hospital LOS compared with patients who continued ChEI therapy in a multivariate linear regression analysis that accounted for admission severity of illness and admission risk of mortality (P=0.007). Rates of ICU admission were low (24%, 115 of 476) and there was no observed difference between groups (14% [6 of 42] for initiation vs 25% [109 of 434] for continuation, P=0.117).

Eleven of the 12 deaths were in patients who were treated with donepezil; however, there was no observed difference in the incidence of mortality for patients treated with donepezil vs patients treated with either rivastigmine or galantamine (3% vs 1%, P=0.479).

Limitations

The major limitation to this study is that the true incidence of delirium in this population is unknown. Unfortunately, acute care patients admitted to our hospital during this study period were not consistently screened for delirium using a validated screening tool. A previous study found that clinicians are unable to diagnose 70% of cases of delirium when a validated delirium screening tool is not used.[18] Therefore, we did not attempt to quantify the incidence of delirium using progress notes or diagnosis codes, as this incidence would be falsely low and unreliable. Our hospital is currently improving the culture of awareness of delirium, and efforts are being made to establish and improve routine screening for delirium in both the acute care and critical care setting.

There were limitations to the outcomes of mortality, readmission, and hospital LOS that were reported. Reported in‐hospital mortality did not account for patients who were transferred for hospice care or patients who were transferred to another facility and subsequently died. Only hospitalizations to TMH were counted for 30‐day readmission rates; admissions to another hospital were unknown. The sample size was too small to estimate the effects of ChEI initiation on 30‐day readmission rates and in‐hospital mortality. Physicians may have been more likely to prescribe ChEI therapy in patients who had prolonged hospital LOS, and the prolonged LOS observed in the ChEI‐initiation group may be confounded by selection bias.

Study Cohort

The DISCHARGE study was a prospective, observational cohort study of patients 65 years or older discharged to home from YaleNew Haven Hospital (YNHH) who were admitted with acute coronary syndrome (ACS), community‐acquired pneumonia, or heart failure (HF). Patients were screened by physicians for eligibility within 24 hours of admission using specialty society guidelines[17, 18, 19, 20] and were enrolled by telephone within 1 week of discharge. Additional inclusion criteria included speaking English or Spanish, and ability of the patient or caregiver to participate in a telephone interview. Patients enrolled in hospice were excluded, as were patients who failed the Mini‐Cog mental status screen (3‐item recall and a clock draw)[21] while in the hospital or appeared confused or delirious during the telephone interview. Caregivers of cognitively impaired patients were eligible for enrollment instead if the patient provided permission.

Study Setting

YNHH is a 966‐bed urban tertiary care hospital with statistically lower than the national average mortality for acute myocardial infarction, HF, and pneumonia but statistically higher than the national average for 30‐day readmission rates for HF and pneumonia at the time this study was conducted. Advanced practice registered nurses (APRNs) working under the supervision of private or university cardiologists provided care for cardiology service patients. Housestaff under the supervision of university or hospitalist attending physicians, or physician assistants or APRNs under the supervision of hospitalist attending physicians provided care for patients on medical services. Discharge summaries were typically dictated by APRNs for cardiology patients, by 2nd‐ or 3rd‐year residents for housestaff patients, and by hospitalists for hospitalist patients. A dictation guideline was provided to housestaff and hospitalists (see Supporting Information, Appendix 1, in the online version of this article); this guideline suggested including basic demographic information, disposition and diagnoses, the admission history and physical, hospital course, discharge medications, and follow‐up appointments. Additionally, housestaff received a lecture about discharge summaries at the start of their 2nd year. Discharge instructions including medications and follow‐up appointment information were automatically appended to the discharge summaries. Summaries were sent by the medical records department only to physicians in the system who were listed by the dictating physician as needing to receive a copy of the summary; no summary was automatically sent (ie, to the primary care physician) if not requested by the dictating physician.

Data Collection

Experienced registered nurses trained in chart abstraction conducted explicit reviews of medical charts using a standardized review tool. The tool included 24 questions about the discharge summary applicable to all 3 conditions, with 7 additional questions for patients with HF and 1 additional question for patients with ACS. These questions included the 6 elements required by The Joint Commission for all discharge summaries (reason for hospitalization, significant findings, procedures and treatment provided, patient's discharge condition, patient and family instructions, and attending physician's signature)[9] as well as the 7 elements (principal diagnosis and problem list, medication list, transferring physician name and contact information, cognitive status of the patient, test results, and pending test results) recommended by the Transitions of Care Consensus Conference (TOCCC), a recent consensus statement produced by 6 major medical societies.[13] Each content element is shown in (see Supporting Information, Appendix 2, in the online version of this article), which also indicates the elements included in the 2 guidelines.

Main Measures

We assessed quality in 3 main domains: timeliness, transmission, and content. We defined timeliness as days between discharge date and dictation date (not final signature date, which may occur later), and measured both median timeliness and proportion of discharge summaries completed on the day of discharge. We defined transmission as successful fax or mail of the discharge summary to an outside physician as reported by the medical records department, and measured the proportion of discharge summaries sent to any outside physician as well as the median number of physicians per discharge summary who were scheduled to follow‐up with the patient postdischarge but who did not receive a copy of the summary. We defined 21 individual content items and assessed the frequency of each individual content item. We also measured compliance with The Joint Commission mandates and TOCCC recommendations, which included several of the individual content items.

To measure compliance with The Joint Commission requirements, we created a composite score in which 1 point was provided for the presence of each of the 6 required elements (maximum score=6). Every discharge summary received 1 point for attending physician signature, because all discharge summaries were electronically signed. Discharge instructions to family/patients were automatically appended to every discharge summary; however, we gave credit for patient and family instructions only to those that included any information about signs and symptoms to monitor for at home. We defined discharge condition as any information about functional status, cognitive status, physical exam, or laboratory findings at discharge.

To measure compliance with specialty society recommendations for discharge summaries, we created a composite score in which 1 point was provided for the presence of each of the 7 recommended elements (maximum score=7). Every discharge summary received 1 point for discharge medications, because these are automatically appended.

We obtained data on age, race, gender, and length of stay from hospital administrative databases. The study was approved by the Yale Human Investigation Committee, and verbal informed consent was obtained from all study participants.

Statistical Analysis

Characteristics of the sample are described with counts and percentages or means and standard deviations. Medians and interquartile ranges (IQRs) or counts and percentages were calculated for summary measures of timeliness, transmission, and content. We assessed differences in quality measures between APRNs, housestaff, and hospitalists using ² tests. We conducted multivariable logistic regression analyses for timeliness and for transmission to any outside physician. All discharge summaries included at least 4 of The Joint Commission elements; consequently, we coded this content outcome as an ordinal variable with 3 levels indicating inclusion of 4, 5, or 6 of The Joint Commission elements. We coded the TOCCC content outcome as a 3‐level variable indicating <4, 4, or >4 elements satisfied. Accordingly, proportional odds models were used, in which the reported odds ratios (ORs) can be interpreted as the average effect of the explanatory variable on the odds of having more recommendations, for any dichotomization of the outcome. Residual analysis and goodness‐of‐fit statistics were used to assess model fit; the proportional odds assumption was tested. Statistical analyses were conducted with SAS 9.2 (SAS Institute, Cary, NC). P values <0.05 were interpreted as statistically significant for 2‐sided tests.

Enrollment and Study Sample

A total of 3743 patients over 64 years old were discharged home from the medical service at YNHH during the study period; 3028 patients were screened for eligibility within 24 hours of admission. We identified 635 eligible admissions and enrolled 395 patients (62.2%) in the study. Of these, 377 granted permission for chart review and were included in this analysis (Figure 1).

Figure 1

The study sample had a mean age of 77.1 years (standard deviation: 7.8); 205 (54.4%) were male and 310 (82.5%) were non‐Hispanic white. A total of 195 (51.7%) had ACS, 91 (24.1%) had pneumonia, and 146 (38.7%) had HF; 54 (14.3%) patients had more than 1 qualifying condition. There were similar numbers of patients on the cardiology, medicine housestaff, and medicine hospitalist teams (Table 1).

Timeliness

Discharge summaries were completed for 376/377 patients, of which 174 (46.3%) were dictated on the day of discharge. However, 122 (32.4%) summaries were dictated more than 48 hours after discharge, including 93 (24.7%) that were dictated more than 1 week after discharge (see Supporting Information, Appendix 3, in the online version of this article).

Summaries dictated by hospitalists were most likely to be done on the day of discharge (35.3% APRNs, 38.2% housestaff, 68.4% hospitalists, P<0.001). After adjustment for diagnosis and length of stay, hospitalists were still significantly more likely to produce a timely discharge summary than APRNs (OR: 2.82; 95% confidence interval [CI]: 1.56‐5.09), whereas housestaff were no different than APRNs (OR: 0.84; 95% CI: 0.48‐1.46).

Transmission

A total of 144 (38.3%) discharge summaries were not sent to any physician besides the inpatient attending, and 209/374 (55.9%) were not sent to at least 1 physician listed as having a follow‐up appointment planned with the patient. Each discharge summary was sent to a median of 1 physician besides the dictating physician (IQR: 01). However, for each summary, a median of 1 physician (IQR: 01) who had a scheduled follow‐up with the patient did not receive the summary. Summaries dictated by hospitalists were most likely to be sent to at least 1 outside physician (54.7% APRNs, 58.5% housestaff, 73.7% hospitalists, P=0.006). Summaries dictated on the day of discharge were more likely than delayed summaries to be sent to at least 1 outside physician (75.9% vs 49.5%, P<0.001). After adjustment for diagnosis and length of stay, there was no longer a difference in likelihood of transmitting a discharge summary to any outpatient physician according to training level; however, dictations completed on the day of discharge remained significantly more likely to be transmitted to an outside physician (OR: 3.05; 95% CI: 1.88‐4.93) (Table 2).

Content

Rate of inclusion of each content element is shown in Table 3, overall and by training level. Nearly every discharge summary included information about admitting diagnosis, hospital course, and procedures or tests performed during the hospitalization. However, few summaries included information about the patient's condition at discharge. Less than half included discharge laboratory results; less than one‐third included functional capacity, cognitive capacity, or discharge physical exam. Only 4.1% overall of discharge summaries for patients with HF included the patient's weight at discharge; best were hospitalists who still included this information in only 7.7% of summaries. Information about postdischarge care, including home social support, pending tests, or recommended follow‐up tests/procedures was also rarely specified. Last, only 6.2% of discharge summaries included the name and contact number of the inpatient physician; this information was least likely to be provided by housestaff (1.6%) and most likely to be provided by hospitalists (15.2%) (P<0.001).

On average, summaries included 5.6 of the 6 Joint Commission elements and 4.0 of the 7 TOCCC elements. A total of 63.0% of discharge summaries included all 6 elements required by The Joint Commission, whereas no discharge summary included all 7 TOCCC elements.

APRNs, housestaff and hospitalists included the same average number of The Joint Commission elements (5.6 each), but hospitalists on average included slightly more TOCCC elements (4.3) than did housestaff (4.0) or APRNs (3.8) (P<0.001). Summaries dictated on the day of discharge included an average of 4.2 TOCCC elements, compared to 3.9 TOCCC elements in delayed discharge. In multivariable analyses adjusted for diagnosis and length of stay, there was still no difference by training level in presence of The Joint Commission elements, but hospitalists were significantly more likely to include more TOCCC elements than APRNs (OR: 2.70; 95% CI: 1.49‐4.90) (Table 4). Summaries dictated on the day of discharge were significantly more likely to include more TOCCC elements (OR: 1.92; 95% CI: 1.23‐2.99).

No discharge summary included all 7 TOCCC‐endorsed content elements, was dictated on the day of discharge, and was sent to an outside physician.

Study Cohort

The DISCHARGE study was a prospective, observational cohort study of patients 65 years or older discharged to home from YaleNew Haven Hospital (YNHH) who were admitted with acute coronary syndrome (ACS), community‐acquired pneumonia, or heart failure (HF). Patients were screened by physicians for eligibility within 24 hours of admission using specialty society guidelines[17, 18, 19, 20] and were enrolled by telephone within 1 week of discharge. Additional inclusion criteria included speaking English or Spanish, and ability of the patient or caregiver to participate in a telephone interview. Patients enrolled in hospice were excluded, as were patients who failed the Mini‐Cog mental status screen (3‐item recall and a clock draw)[21] while in the hospital or appeared confused or delirious during the telephone interview. Caregivers of cognitively impaired patients were eligible for enrollment instead if the patient provided permission.

Study Setting

YNHH is a 966‐bed urban tertiary care hospital with statistically lower than the national average mortality for acute myocardial infarction, HF, and pneumonia but statistically higher than the national average for 30‐day readmission rates for HF and pneumonia at the time this study was conducted. Advanced practice registered nurses (APRNs) working under the supervision of private or university cardiologists provided care for cardiology service patients. Housestaff under the supervision of university or hospitalist attending physicians, or physician assistants or APRNs under the supervision of hospitalist attending physicians provided care for patients on medical services. Discharge summaries were typically dictated by APRNs for cardiology patients, by 2nd‐ or 3rd‐year residents for housestaff patients, and by hospitalists for hospitalist patients. A dictation guideline was provided to housestaff and hospitalists (see Supporting Information, Appendix 1, in the online version of this article); this guideline suggested including basic demographic information, disposition and diagnoses, the admission history and physical, hospital course, discharge medications, and follow‐up appointments. Additionally, housestaff received a lecture about discharge summaries at the start of their 2nd year. Discharge instructions including medications and follow‐up appointment information were automatically appended to the discharge summaries. Summaries were sent by the medical records department only to physicians in the system who were listed by the dictating physician as needing to receive a copy of the summary; no summary was automatically sent (ie, to the primary care physician) if not requested by the dictating physician.

Data Collection

Experienced registered nurses trained in chart abstraction conducted explicit reviews of medical charts using a standardized review tool. The tool included 24 questions about the discharge summary applicable to all 3 conditions, with 7 additional questions for patients with HF and 1 additional question for patients with ACS. These questions included the 6 elements required by The Joint Commission for all discharge summaries (reason for hospitalization, significant findings, procedures and treatment provided, patient's discharge condition, patient and family instructions, and attending physician's signature)[9] as well as the 7 elements (principal diagnosis and problem list, medication list, transferring physician name and contact information, cognitive status of the patient, test results, and pending test results) recommended by the Transitions of Care Consensus Conference (TOCCC), a recent consensus statement produced by 6 major medical societies.[13] Each content element is shown in (see Supporting Information, Appendix 2, in the online version of this article), which also indicates the elements included in the 2 guidelines.

Main Measures

We assessed quality in 3 main domains: timeliness, transmission, and content. We defined timeliness as days between discharge date and dictation date (not final signature date, which may occur later), and measured both median timeliness and proportion of discharge summaries completed on the day of discharge. We defined transmission as successful fax or mail of the discharge summary to an outside physician as reported by the medical records department, and measured the proportion of discharge summaries sent to any outside physician as well as the median number of physicians per discharge summary who were scheduled to follow‐up with the patient postdischarge but who did not receive a copy of the summary. We defined 21 individual content items and assessed the frequency of each individual content item. We also measured compliance with The Joint Commission mandates and TOCCC recommendations, which included several of the individual content items.

To measure compliance with The Joint Commission requirements, we created a composite score in which 1 point was provided for the presence of each of the 6 required elements (maximum score=6). Every discharge summary received 1 point for attending physician signature, because all discharge summaries were electronically signed. Discharge instructions to family/patients were automatically appended to every discharge summary; however, we gave credit for patient and family instructions only to those that included any information about signs and symptoms to monitor for at home. We defined discharge condition as any information about functional status, cognitive status, physical exam, or laboratory findings at discharge.

To measure compliance with specialty society recommendations for discharge summaries, we created a composite score in which 1 point was provided for the presence of each of the 7 recommended elements (maximum score=7). Every discharge summary received 1 point for discharge medications, because these are automatically appended.

We obtained data on age, race, gender, and length of stay from hospital administrative databases. The study was approved by the Yale Human Investigation Committee, and verbal informed consent was obtained from all study participants.

Statistical Analysis

Characteristics of the sample are described with counts and percentages or means and standard deviations. Medians and interquartile ranges (IQRs) or counts and percentages were calculated for summary measures of timeliness, transmission, and content. We assessed differences in quality measures between APRNs, housestaff, and hospitalists using ² tests. We conducted multivariable logistic regression analyses for timeliness and for transmission to any outside physician. All discharge summaries included at least 4 of The Joint Commission elements; consequently, we coded this content outcome as an ordinal variable with 3 levels indicating inclusion of 4, 5, or 6 of The Joint Commission elements. We coded the TOCCC content outcome as a 3‐level variable indicating <4, 4, or >4 elements satisfied. Accordingly, proportional odds models were used, in which the reported odds ratios (ORs) can be interpreted as the average effect of the explanatory variable on the odds of having more recommendations, for any dichotomization of the outcome. Residual analysis and goodness‐of‐fit statistics were used to assess model fit; the proportional odds assumption was tested. Statistical analyses were conducted with SAS 9.2 (SAS Institute, Cary, NC). P values <0.05 were interpreted as statistically significant for 2‐sided tests.

Enrollment and Study Sample

A total of 3743 patients over 64 years old were discharged home from the medical service at YNHH during the study period; 3028 patients were screened for eligibility within 24 hours of admission. We identified 635 eligible admissions and enrolled 395 patients (62.2%) in the study. Of these, 377 granted permission for chart review and were included in this analysis (Figure 1).

Figure 1

The study sample had a mean age of 77.1 years (standard deviation: 7.8); 205 (54.4%) were male and 310 (82.5%) were non‐Hispanic white. A total of 195 (51.7%) had ACS, 91 (24.1%) had pneumonia, and 146 (38.7%) had HF; 54 (14.3%) patients had more than 1 qualifying condition. There were similar numbers of patients on the cardiology, medicine housestaff, and medicine hospitalist teams (Table 1).

Timeliness

Discharge summaries were completed for 376/377 patients, of which 174 (46.3%) were dictated on the day of discharge. However, 122 (32.4%) summaries were dictated more than 48 hours after discharge, including 93 (24.7%) that were dictated more than 1 week after discharge (see Supporting Information, Appendix 3, in the online version of this article).

Summaries dictated by hospitalists were most likely to be done on the day of discharge (35.3% APRNs, 38.2% housestaff, 68.4% hospitalists, P<0.001). After adjustment for diagnosis and length of stay, hospitalists were still significantly more likely to produce a timely discharge summary than APRNs (OR: 2.82; 95% confidence interval [CI]: 1.56‐5.09), whereas housestaff were no different than APRNs (OR: 0.84; 95% CI: 0.48‐1.46).

Transmission

A total of 144 (38.3%) discharge summaries were not sent to any physician besides the inpatient attending, and 209/374 (55.9%) were not sent to at least 1 physician listed as having a follow‐up appointment planned with the patient. Each discharge summary was sent to a median of 1 physician besides the dictating physician (IQR: 01). However, for each summary, a median of 1 physician (IQR: 01) who had a scheduled follow‐up with the patient did not receive the summary. Summaries dictated by hospitalists were most likely to be sent to at least 1 outside physician (54.7% APRNs, 58.5% housestaff, 73.7% hospitalists, P=0.006). Summaries dictated on the day of discharge were more likely than delayed summaries to be sent to at least 1 outside physician (75.9% vs 49.5%, P<0.001). After adjustment for diagnosis and length of stay, there was no longer a difference in likelihood of transmitting a discharge summary to any outpatient physician according to training level; however, dictations completed on the day of discharge remained significantly more likely to be transmitted to an outside physician (OR: 3.05; 95% CI: 1.88‐4.93) (Table 2).

Content

Rate of inclusion of each content element is shown in Table 3, overall and by training level. Nearly every discharge summary included information about admitting diagnosis, hospital course, and procedures or tests performed during the hospitalization. However, few summaries included information about the patient's condition at discharge. Less than half included discharge laboratory results; less than one‐third included functional capacity, cognitive capacity, or discharge physical exam. Only 4.1% overall of discharge summaries for patients with HF included the patient's weight at discharge; best were hospitalists who still included this information in only 7.7% of summaries. Information about postdischarge care, including home social support, pending tests, or recommended follow‐up tests/procedures was also rarely specified. Last, only 6.2% of discharge summaries included the name and contact number of the inpatient physician; this information was least likely to be provided by housestaff (1.6%) and most likely to be provided by hospitalists (15.2%) (P<0.001).

On average, summaries included 5.6 of the 6 Joint Commission elements and 4.0 of the 7 TOCCC elements. A total of 63.0% of discharge summaries included all 6 elements required by The Joint Commission, whereas no discharge summary included all 7 TOCCC elements.

APRNs, housestaff and hospitalists included the same average number of The Joint Commission elements (5.6 each), but hospitalists on average included slightly more TOCCC elements (4.3) than did housestaff (4.0) or APRNs (3.8) (P<0.001). Summaries dictated on the day of discharge included an average of 4.2 TOCCC elements, compared to 3.9 TOCCC elements in delayed discharge. In multivariable analyses adjusted for diagnosis and length of stay, there was still no difference by training level in presence of The Joint Commission elements, but hospitalists were significantly more likely to include more TOCCC elements than APRNs (OR: 2.70; 95% CI: 1.49‐4.90) (Table 4). Summaries dictated on the day of discharge were significantly more likely to include more TOCCC elements (OR: 1.92; 95% CI: 1.23‐2.99).

No discharge summary included all 7 TOCCC‐endorsed content elements, was dictated on the day of discharge, and was sent to an outside physician.

Study Cohort

The DISCHARGE study was a prospective, observational cohort study of patients 65 years or older discharged to home from YaleNew Haven Hospital (YNHH) who were admitted with acute coronary syndrome (ACS), community‐acquired pneumonia, or heart failure (HF). Patients were screened by physicians for eligibility within 24 hours of admission using specialty society guidelines[17, 18, 19, 20] and were enrolled by telephone within 1 week of discharge. Additional inclusion criteria included speaking English or Spanish, and ability of the patient or caregiver to participate in a telephone interview. Patients enrolled in hospice were excluded, as were patients who failed the Mini‐Cog mental status screen (3‐item recall and a clock draw)[21] while in the hospital or appeared confused or delirious during the telephone interview. Caregivers of cognitively impaired patients were eligible for enrollment instead if the patient provided permission.

Study Setting

YNHH is a 966‐bed urban tertiary care hospital with statistically lower than the national average mortality for acute myocardial infarction, HF, and pneumonia but statistically higher than the national average for 30‐day readmission rates for HF and pneumonia at the time this study was conducted. Advanced practice registered nurses (APRNs) working under the supervision of private or university cardiologists provided care for cardiology service patients. Housestaff under the supervision of university or hospitalist attending physicians, or physician assistants or APRNs under the supervision of hospitalist attending physicians provided care for patients on medical services. Discharge summaries were typically dictated by APRNs for cardiology patients, by 2nd‐ or 3rd‐year residents for housestaff patients, and by hospitalists for hospitalist patients. A dictation guideline was provided to housestaff and hospitalists (see Supporting Information, Appendix 1, in the online version of this article); this guideline suggested including basic demographic information, disposition and diagnoses, the admission history and physical, hospital course, discharge medications, and follow‐up appointments. Additionally, housestaff received a lecture about discharge summaries at the start of their 2nd year. Discharge instructions including medications and follow‐up appointment information were automatically appended to the discharge summaries. Summaries were sent by the medical records department only to physicians in the system who were listed by the dictating physician as needing to receive a copy of the summary; no summary was automatically sent (ie, to the primary care physician) if not requested by the dictating physician.

Data Collection

Experienced registered nurses trained in chart abstraction conducted explicit reviews of medical charts using a standardized review tool. The tool included 24 questions about the discharge summary applicable to all 3 conditions, with 7 additional questions for patients with HF and 1 additional question for patients with ACS. These questions included the 6 elements required by The Joint Commission for all discharge summaries (reason for hospitalization, significant findings, procedures and treatment provided, patient's discharge condition, patient and family instructions, and attending physician's signature)[9] as well as the 7 elements (principal diagnosis and problem list, medication list, transferring physician name and contact information, cognitive status of the patient, test results, and pending test results) recommended by the Transitions of Care Consensus Conference (TOCCC), a recent consensus statement produced by 6 major medical societies.[13] Each content element is shown in (see Supporting Information, Appendix 2, in the online version of this article), which also indicates the elements included in the 2 guidelines.

Main Measures

We assessed quality in 3 main domains: timeliness, transmission, and content. We defined timeliness as days between discharge date and dictation date (not final signature date, which may occur later), and measured both median timeliness and proportion of discharge summaries completed on the day of discharge. We defined transmission as successful fax or mail of the discharge summary to an outside physician as reported by the medical records department, and measured the proportion of discharge summaries sent to any outside physician as well as the median number of physicians per discharge summary who were scheduled to follow‐up with the patient postdischarge but who did not receive a copy of the summary. We defined 21 individual content items and assessed the frequency of each individual content item. We also measured compliance with The Joint Commission mandates and TOCCC recommendations, which included several of the individual content items.

To measure compliance with The Joint Commission requirements, we created a composite score in which 1 point was provided for the presence of each of the 6 required elements (maximum score=6). Every discharge summary received 1 point for attending physician signature, because all discharge summaries were electronically signed. Discharge instructions to family/patients were automatically appended to every discharge summary; however, we gave credit for patient and family instructions only to those that included any information about signs and symptoms to monitor for at home. We defined discharge condition as any information about functional status, cognitive status, physical exam, or laboratory findings at discharge.

To measure compliance with specialty society recommendations for discharge summaries, we created a composite score in which 1 point was provided for the presence of each of the 7 recommended elements (maximum score=7). Every discharge summary received 1 point for discharge medications, because these are automatically appended.

We obtained data on age, race, gender, and length of stay from hospital administrative databases. The study was approved by the Yale Human Investigation Committee, and verbal informed consent was obtained from all study participants.

Statistical Analysis

Characteristics of the sample are described with counts and percentages or means and standard deviations. Medians and interquartile ranges (IQRs) or counts and percentages were calculated for summary measures of timeliness, transmission, and content. We assessed differences in quality measures between APRNs, housestaff, and hospitalists using ² tests. We conducted multivariable logistic regression analyses for timeliness and for transmission to any outside physician. All discharge summaries included at least 4 of The Joint Commission elements; consequently, we coded this content outcome as an ordinal variable with 3 levels indicating inclusion of 4, 5, or 6 of The Joint Commission elements. We coded the TOCCC content outcome as a 3‐level variable indicating <4, 4, or >4 elements satisfied. Accordingly, proportional odds models were used, in which the reported odds ratios (ORs) can be interpreted as the average effect of the explanatory variable on the odds of having more recommendations, for any dichotomization of the outcome. Residual analysis and goodness‐of‐fit statistics were used to assess model fit; the proportional odds assumption was tested. Statistical analyses were conducted with SAS 9.2 (SAS Institute, Cary, NC). P values <0.05 were interpreted as statistically significant for 2‐sided tests.

Enrollment and Study Sample

A total of 3743 patients over 64 years old were discharged home from the medical service at YNHH during the study period; 3028 patients were screened for eligibility within 24 hours of admission. We identified 635 eligible admissions and enrolled 395 patients (62.2%) in the study. Of these, 377 granted permission for chart review and were included in this analysis (Figure 1).

Figure 1

The study sample had a mean age of 77.1 years (standard deviation: 7.8); 205 (54.4%) were male and 310 (82.5%) were non‐Hispanic white. A total of 195 (51.7%) had ACS, 91 (24.1%) had pneumonia, and 146 (38.7%) had HF; 54 (14.3%) patients had more than 1 qualifying condition. There were similar numbers of patients on the cardiology, medicine housestaff, and medicine hospitalist teams (Table 1).

Timeliness

Discharge summaries were completed for 376/377 patients, of which 174 (46.3%) were dictated on the day of discharge. However, 122 (32.4%) summaries were dictated more than 48 hours after discharge, including 93 (24.7%) that were dictated more than 1 week after discharge (see Supporting Information, Appendix 3, in the online version of this article).

Summaries dictated by hospitalists were most likely to be done on the day of discharge (35.3% APRNs, 38.2% housestaff, 68.4% hospitalists, P<0.001). After adjustment for diagnosis and length of stay, hospitalists were still significantly more likely to produce a timely discharge summary than APRNs (OR: 2.82; 95% confidence interval [CI]: 1.56‐5.09), whereas housestaff were no different than APRNs (OR: 0.84; 95% CI: 0.48‐1.46).

Transmission

A total of 144 (38.3%) discharge summaries were not sent to any physician besides the inpatient attending, and 209/374 (55.9%) were not sent to at least 1 physician listed as having a follow‐up appointment planned with the patient. Each discharge summary was sent to a median of 1 physician besides the dictating physician (IQR: 01). However, for each summary, a median of 1 physician (IQR: 01) who had a scheduled follow‐up with the patient did not receive the summary. Summaries dictated by hospitalists were most likely to be sent to at least 1 outside physician (54.7% APRNs, 58.5% housestaff, 73.7% hospitalists, P=0.006). Summaries dictated on the day of discharge were more likely than delayed summaries to be sent to at least 1 outside physician (75.9% vs 49.5%, P<0.001). After adjustment for diagnosis and length of stay, there was no longer a difference in likelihood of transmitting a discharge summary to any outpatient physician according to training level; however, dictations completed on the day of discharge remained significantly more likely to be transmitted to an outside physician (OR: 3.05; 95% CI: 1.88‐4.93) (Table 2).

Content

Rate of inclusion of each content element is shown in Table 3, overall and by training level. Nearly every discharge summary included information about admitting diagnosis, hospital course, and procedures or tests performed during the hospitalization. However, few summaries included information about the patient's condition at discharge. Less than half included discharge laboratory results; less than one‐third included functional capacity, cognitive capacity, or discharge physical exam. Only 4.1% overall of discharge summaries for patients with HF included the patient's weight at discharge; best were hospitalists who still included this information in only 7.7% of summaries. Information about postdischarge care, including home social support, pending tests, or recommended follow‐up tests/procedures was also rarely specified. Last, only 6.2% of discharge summaries included the name and contact number of the inpatient physician; this information was least likely to be provided by housestaff (1.6%) and most likely to be provided by hospitalists (15.2%) (P<0.001).

On average, summaries included 5.6 of the 6 Joint Commission elements and 4.0 of the 7 TOCCC elements. A total of 63.0% of discharge summaries included all 6 elements required by The Joint Commission, whereas no discharge summary included all 7 TOCCC elements.

APRNs, housestaff and hospitalists included the same average number of The Joint Commission elements (5.6 each), but hospitalists on average included slightly more TOCCC elements (4.3) than did housestaff (4.0) or APRNs (3.8) (P<0.001). Summaries dictated on the day of discharge included an average of 4.2 TOCCC elements, compared to 3.9 TOCCC elements in delayed discharge. In multivariable analyses adjusted for diagnosis and length of stay, there was still no difference by training level in presence of The Joint Commission elements, but hospitalists were significantly more likely to include more TOCCC elements than APRNs (OR: 2.70; 95% CI: 1.49‐4.90) (Table 4). Summaries dictated on the day of discharge were significantly more likely to include more TOCCC elements (OR: 1.92; 95% CI: 1.23‐2.99).

No discharge summary included all 7 TOCCC‐endorsed content elements, was dictated on the day of discharge, and was sent to an outside physician.