EARLY PHYSICIAN FOLLOW‐UP AFTER HOSPITALIZATION FOR HEART FAILURE IS ALSO RELEVANT

Abstract

To the Editor: Given that cardiovascular disorders (including congestive heart failure) account for the majority of potentially avoidable hospitalizations of nursing home residents1 and that “the days immediately following discharge are a vulnerable period” for patients with heart failure,2 it was an omission on the part of Ouslander and colleagues1 not to evaluate the relationship between early physician follow-up and readmission rates for nursing home residents with heart failure. Early physician follow-up generates an opportunity to evaluate the patient's clinical status outside of the highly structured hospital setting and to review therapeutic strategies accordingly.2 This might well be the reason why, in that study, there was a significant (P<.01) inverse relationship between early follow-up and the hazard of 30-day readmission.2 To compound the deleterious effects of suboptimal follow-up, in many hospitals, “the discharge instructions are becoming rote processes that do not adequately address elements of care that ensure a safe transition [to primary care],”2 and it is my belief is that this is especially true when the highly demanding duty to compose a meaningful discharge summary is relegated, without proper supervision or monitoring, to junior staff, some of whom regard it as a mindless chore, devoid of any contribution toward continuing professional development.3 One of the defining characteristics of discharge summaries that have degenerated into rote processes or mindless chores is the failure to highlight adverse drug reactions, leading, in one example, to postdischarge rechallenge with thiazide diuretics in the instance of a patient previously admitted with severe thiazide-related hyponatremia.4 My own belief is that the use of an integrated health record (a so-called core medical record) in secondary and tertiary care, characterized by a problem-oriented integration of contributions from the entire healthcare team,5, 6 as opposed to the system of separate medical and nursing notes prevailing in some if not most hospitals in the United Kingdom, will enhance the timing of discharge and the potential to generate discharge summaries of greatest value to primary care. Furthermore, to “weed out” inaccuracies identified by one audit,7 discharge summaries should be audited on a regular basis,6 and this should be part of good clinical governance. Finally, to ease the transition from hospital to the less highly structured environment of the nursing home, the hospital discharge program should be reengineered to engage the services of a nurse discharge advocate to coordinate the discharge plan with the hospital team and to transmit a problem-orientated discharge summary to physicians and services accepting responsibility for the patient's care and the services of a clinical pharmacist to call on patients within the first week of discharge to reinforce the discharge plan and review all medications.8 Participants in one such program also have significantly (P=.009) lower rehospitalizations than participants receiving “usual” care.8 Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: The author is the sole contributor to this paper. Sponsor's Role: None.