Sunil Kripalani, MD, MSc

The period immediately following hospital discharge is a vulnerable time for patients, who must assume responsibilities for their own care as they return home.1 The process of hospital discharge may be a rushed event, and patients often have difficulty understanding and following their postdischarge treatment plan.2, 3 Medication‐related problems after hospital discharge, which include patients not filling or refilling prescriptions,46 not understanding how to take medications,2, 3 showing discrepancies between what they are and what they should be taking,79 and having adverse drug events,1012 are a major cause of morbidity and mortality.13

According to prior studies, elderly patients and patients taking more than 5 medications are more likely to experience problems with their medications.5, 14 Adverse drug events are more common with certain high‐risk drugs, including cardiovascular agents, anticoagulants, insulin, antibiotics, and steroids.11, 14, 15 Beyond this, however, patient management of prescription medications after hospital discharge has not been well described. In particular, studies in the community setting and in the immediate postdischarge period are needed.

We conducted a large observational study of patients at 170 community hospitals in order to examine the frequency of prescription‐related issues 4872 hours after hospital discharge. These issues included problems with filling or taking medications prescribed at discharge. We hypothesized that age and number of medications would be independently associated with prescription‐related problems. We also examined the effects of other factors, including insurance type, length of stay, severity of illness (SOI), clinical diagnosis, and use of certain high‐risk drugs.

METHODS

RESULTS

In 2005, there were 104,506 eligible adult hospital discharges, corresponding to 96,179 patients. Excluding discharged patients who could not be contacted by the call center or who refused to complete the survey (n = 67,084), multiple surveys of the same patient (n = 3156), and surveys with insufficient data to determine whether there were prescription‐related issues (n = 3067) left 31,199 patients available for analysis (effective response rate 32.4%).

More than half the participants (57.0%) were women, and the mean age was 61.1 years (SD 17.8 years). The median number of discharge medications was 4 (range 128). The most frequently prescribed drugs were antibiotics and analgesics, followed by several cardiovascular drug classes (Table 1). About 60% of the primary diagnoses were of circulatory, digestive, and respiratory disorders (Table 1). Compared with nonparticipants, the study sample was more likely to be female, older, and covered by Medicare. Study patients also had greater comorbidity, as indicated by greater severity of illness rating and number of discharge medications.

Overall, 7.2% of patients (n = 2253) had prescription‐related issues 4872 hours after hospital discharge. This included not picking up prescribed discharge medications (n = 1797, or 79.8% of issues), not knowing if they were picked up (n = 55 or 2.4%), and admitting to not taking (n = 154, or 6.8%) or not understanding how to take (n = 247, or 11%) medications.

In unadjusted analyses, prescription‐related issues were significantly associated with age, sex, insurance type, severity of illness rating, length of stay, number of discharge medications, certain medication types, and major diagnostic category (Table 2). Except for the youngest patients (age < 35 years), having prescription‐related issues appeared to be inversely related to patient age. Adults 3549 years old had the highest frequency of problems filling or taking medications (9.3%), whereas patients 80 years or older had the lowest frequency (5.6%). Analysis by insurance status showed that patients with Medicaid (12.6%) or self‐pay/uninsured status (11.9%) had significantly higher rates of prescription issues and patients with non‐Medicare HMO or commercial insurance had significantly lower rates (6.1% and 4.9%, respectively). Being prescribed at least 6 medications or taking ACE inhibitors, inhalers, oral hypoglycemics, or insulins was also associated with a higher frequency of prescription‐related problems in unadjusted analyses. Patients prescribed antibiotics or anticoagulants were less likely to report problems in unadjusted analyses.

In multivariable models, age, sex, insurance type, severity of illness, number of medications, and certain medication types were independently associated with prescription‐related issues after discharge (Table 3). Seniors reported significantly fewer problems than the youngest patients (6579 years, OR 0.69; 80 years, OR 0.59). Those with Medicare HMOs, Medicaid, or no insurance had more difficulty obtaining and taking prescription medications (OR 1.29, 1.33, and 1.31, respectively), whereas patients with HMO or commercial insurance plans had less difficulty (OR 0.68 and 0.51, respectively). Prescription‐related problems were also more common among women (OR 1.11), patients with higher severity of illness (moderate SOI, OR 1.12; major/extreme SOI, OR 1.23), and those with 6 or more discharge medications (OR 1.35). In adjusted analyses, inhalers were the only type of medication associated with a significantly higher frequency of problems (OR 1.14).

Analyses were repeated using only failure to pick up medications as the dependent variable, and results were similar (not shown).

DISCUSSION

In this large multicenter study, 7.2% of patients reported problems obtaining or taking prescribed medications in the 4872 hours following hospital discharge. In about 80% of cases, the problem was failure to pick up discharge medications. Multivariable analyses showed adults 3549 years old; women; patients with Medicare HMO insurance, Medicaid, or no coverage (self‐pay); adults with high severity of illness rating; and those prescribed more than 5 medications or an inhaler had significantly greater odds of prescription‐related issues. Other factors were protective including age 65 or older; HMO or commercial insurance; prescription of antibiotics, anticoagulants, or angiotensin II receptor blockers; and major diagnosis in the skin or musculoskeletal category.

Among all the groups studied, patients with Medicaid or no insurance had the highest frequency of problems filling and taking discharge medications (12.6% and 11.9%, respectively). This was likely related to their having less prescription drug coverage or experiencing other financial constraints. In previous studies, patients have expressed concern over the rising cost of medications and have admitted to not filling prescriptions or stretching out the use of medications to make them last longer because of high out‐of‐pocket costs.5, 16 Prescriptions given at hospital discharge may pose a significant unexpected expense for patients who have a fixed monthly income, rely on samples from outpatient physicians for their medications, or need time to research cost‐saving measures such as discount plans. Greater attention by physicians to knowing the cost of discharge medications, to prescribing only those drugs that are truly necessary, and to discussing cost‐saving strategies with patients may help to minimize financial concerns and improve the ability of patients to fill discharge prescriptions.17

The finding that polypharmacy is associated with greater odds of prescription‐related issues is consistent with research that found that other medication problems such as adverse drug events and nonadherence were more prevalent among patients prescribed more than 5 medications.5, 14 Polypharmacy may have contributed to prescription‐related difficulties in this study by increasing medication costs or by increasing the chance that patients had a problem with at least 1 medication.

The higher frequency of prescription‐related issues among patients prescribed inhalers indicates that this category of medication may be associated with lower fill rates or greater confusion after discharge. This would be concerning, given that repeat exacerbations of obstructive lung disease may lead to rehospitalization. Other medications, including anticoagulants and antibiotics, were associated with a lower frequency of problems. This may have been the result of better education at discharge about the importance of promptly filling prescriptions for these agents in order to avoid a lapse in therapy following acute treatment for thromboembolic disorders or acute infections. It is hoped that a similar educational effort about filling prescriptions for inhalers also would have occurred. These effects have not been noted in prior research and require further substantiation.11, 14 Also, the observed relationships may be related to the size of the data set and the number of variables considered, rather than to a true effect.

The main strength of this study was that the data from which conclusions were drawn came from a large and geographically diverse patient population. However, the study also had several limitations. First, the response rate was relatively low, primarily because this study was a retrospective analysis performed using data collected for clinical and administrative reasons. Patient contact number was missing or incorrect in 16% of cases. Also, because of the narrow window of time during which the survey was administered, the call center, which was following up an average of 370 discharged patients per day, was only able to make 1 or 2 attempts to reach each patient. This contrasts with prospective research on postdischarge medication use such as the study by Forster and colleagues, in which the investigator made up to 20 attempts to reach patients at different times and on different days.11 Despite these efforts, the follow‐up rate was only 69%, underscoring the challenge of data collection in this setting.

The low response rate raises the possibility that the estimated prevalence of prescription‐related issues may be inaccurate. Although highly unlikely, if all the nonresponders had problems with their prescriptions, the true event rate would be 69.9%. Conversely, if none of the nonresponders had problems, the true event rate would be 2.3%. Given the characteristics of responders and nonresponders, however, we expect that a higher survey completion rate would have yielded similar results. Nonresponders had certain characteristics that would be expected to be associated with a higher frequency of prescription‐related issues (younger age, uninsured, covered by Medicaid), but these were balanced by others that would be expected to be associated with a lower frequency of problems (higher percentage of men, lower severity of illness, fewer medications).

Another study limitation concerns the self‐reported nature of the composite outcome variable. After reviewing the structure of the call center data, we chose this composite measure because it conceptually represented difficulties in obtaining or taking prescribed discharge medications. When we analyzed results using only the most prevalent component of this composite variable, the results were similar. However, all these findings could have been influenced by social desirability bias. Patients may have underreported not filling their discharge prescriptions and also may not acknowledged difficulties in understanding how to take the medications. We would therefore expect the true prevalence of prescription‐related concerns after hospital discharge to be higher than that found in this study.

These limitations notwithstanding, the findings from this large, multicenter study show that prescription‐related issues are common after hospital discharge and, further, that they usually take the form of not filling discharge prescriptions. The highest‐risk patients appear to be those without insurance and those covered by Medicaid or Medicare HMOs, as well as adults age 3549, patients prescribed 6 or more medications, and patients with a higher severity of illness. When preparing patients to leave the hospital, physicians and other health care providers should strive to identify financial, behavioral, and other barriers to proper medication use so that appropriate assistance or counseling may be offered prior to discharge.18, 19 Close follow‐up of patients by telephone may also be a helpful approach to promptly identifying prescription‐related issues and other problems so that providers can intervene before more serious complications arise.

The period immediately following hospital discharge is a vulnerable time for patients, who must assume responsibilities for their own care as they return home.1 The process of hospital discharge may be a rushed event, and patients often have difficulty understanding and following their postdischarge treatment plan.2, 3 Medication‐related problems after hospital discharge, which include patients not filling or refilling prescriptions,46 not understanding how to take medications,2, 3 showing discrepancies between what they are and what they should be taking,79 and having adverse drug events,1012 are a major cause of morbidity and mortality.13

According to prior studies, elderly patients and patients taking more than 5 medications are more likely to experience problems with their medications.5, 14 Adverse drug events are more common with certain high‐risk drugs, including cardiovascular agents, anticoagulants, insulin, antibiotics, and steroids.11, 14, 15 Beyond this, however, patient management of prescription medications after hospital discharge has not been well described. In particular, studies in the community setting and in the immediate postdischarge period are needed.

We conducted a large observational study of patients at 170 community hospitals in order to examine the frequency of prescription‐related issues 4872 hours after hospital discharge. These issues included problems with filling or taking medications prescribed at discharge. We hypothesized that age and number of medications would be independently associated with prescription‐related problems. We also examined the effects of other factors, including insurance type, length of stay, severity of illness (SOI), clinical diagnosis, and use of certain high‐risk drugs.

METHODS

RESULTS

In 2005, there were 104,506 eligible adult hospital discharges, corresponding to 96,179 patients. Excluding discharged patients who could not be contacted by the call center or who refused to complete the survey (n = 67,084), multiple surveys of the same patient (n = 3156), and surveys with insufficient data to determine whether there were prescription‐related issues (n = 3067) left 31,199 patients available for analysis (effective response rate 32.4%).

More than half the participants (57.0%) were women, and the mean age was 61.1 years (SD 17.8 years). The median number of discharge medications was 4 (range 128). The most frequently prescribed drugs were antibiotics and analgesics, followed by several cardiovascular drug classes (Table 1). About 60% of the primary diagnoses were of circulatory, digestive, and respiratory disorders (Table 1). Compared with nonparticipants, the study sample was more likely to be female, older, and covered by Medicare. Study patients also had greater comorbidity, as indicated by greater severity of illness rating and number of discharge medications.

Overall, 7.2% of patients (n = 2253) had prescription‐related issues 4872 hours after hospital discharge. This included not picking up prescribed discharge medications (n = 1797, or 79.8% of issues), not knowing if they were picked up (n = 55 or 2.4%), and admitting to not taking (n = 154, or 6.8%) or not understanding how to take (n = 247, or 11%) medications.

In unadjusted analyses, prescription‐related issues were significantly associated with age, sex, insurance type, severity of illness rating, length of stay, number of discharge medications, certain medication types, and major diagnostic category (Table 2). Except for the youngest patients (age < 35 years), having prescription‐related issues appeared to be inversely related to patient age. Adults 3549 years old had the highest frequency of problems filling or taking medications (9.3%), whereas patients 80 years or older had the lowest frequency (5.6%). Analysis by insurance status showed that patients with Medicaid (12.6%) or self‐pay/uninsured status (11.9%) had significantly higher rates of prescription issues and patients with non‐Medicare HMO or commercial insurance had significantly lower rates (6.1% and 4.9%, respectively). Being prescribed at least 6 medications or taking ACE inhibitors, inhalers, oral hypoglycemics, or insulins was also associated with a higher frequency of prescription‐related problems in unadjusted analyses. Patients prescribed antibiotics or anticoagulants were less likely to report problems in unadjusted analyses.

In multivariable models, age, sex, insurance type, severity of illness, number of medications, and certain medication types were independently associated with prescription‐related issues after discharge (Table 3). Seniors reported significantly fewer problems than the youngest patients (6579 years, OR 0.69; 80 years, OR 0.59). Those with Medicare HMOs, Medicaid, or no insurance had more difficulty obtaining and taking prescription medications (OR 1.29, 1.33, and 1.31, respectively), whereas patients with HMO or commercial insurance plans had less difficulty (OR 0.68 and 0.51, respectively). Prescription‐related problems were also more common among women (OR 1.11), patients with higher severity of illness (moderate SOI, OR 1.12; major/extreme SOI, OR 1.23), and those with 6 or more discharge medications (OR 1.35). In adjusted analyses, inhalers were the only type of medication associated with a significantly higher frequency of problems (OR 1.14).

Analyses were repeated using only failure to pick up medications as the dependent variable, and results were similar (not shown).

DISCUSSION

In this large multicenter study, 7.2% of patients reported problems obtaining or taking prescribed medications in the 4872 hours following hospital discharge. In about 80% of cases, the problem was failure to pick up discharge medications. Multivariable analyses showed adults 3549 years old; women; patients with Medicare HMO insurance, Medicaid, or no coverage (self‐pay); adults with high severity of illness rating; and those prescribed more than 5 medications or an inhaler had significantly greater odds of prescription‐related issues. Other factors were protective including age 65 or older; HMO or commercial insurance; prescription of antibiotics, anticoagulants, or angiotensin II receptor blockers; and major diagnosis in the skin or musculoskeletal category.

Among all the groups studied, patients with Medicaid or no insurance had the highest frequency of problems filling and taking discharge medications (12.6% and 11.9%, respectively). This was likely related to their having less prescription drug coverage or experiencing other financial constraints. In previous studies, patients have expressed concern over the rising cost of medications and have admitted to not filling prescriptions or stretching out the use of medications to make them last longer because of high out‐of‐pocket costs.5, 16 Prescriptions given at hospital discharge may pose a significant unexpected expense for patients who have a fixed monthly income, rely on samples from outpatient physicians for their medications, or need time to research cost‐saving measures such as discount plans. Greater attention by physicians to knowing the cost of discharge medications, to prescribing only those drugs that are truly necessary, and to discussing cost‐saving strategies with patients may help to minimize financial concerns and improve the ability of patients to fill discharge prescriptions.17

The finding that polypharmacy is associated with greater odds of prescription‐related issues is consistent with research that found that other medication problems such as adverse drug events and nonadherence were more prevalent among patients prescribed more than 5 medications.5, 14 Polypharmacy may have contributed to prescription‐related difficulties in this study by increasing medication costs or by increasing the chance that patients had a problem with at least 1 medication.

The higher frequency of prescription‐related issues among patients prescribed inhalers indicates that this category of medication may be associated with lower fill rates or greater confusion after discharge. This would be concerning, given that repeat exacerbations of obstructive lung disease may lead to rehospitalization. Other medications, including anticoagulants and antibiotics, were associated with a lower frequency of problems. This may have been the result of better education at discharge about the importance of promptly filling prescriptions for these agents in order to avoid a lapse in therapy following acute treatment for thromboembolic disorders or acute infections. It is hoped that a similar educational effort about filling prescriptions for inhalers also would have occurred. These effects have not been noted in prior research and require further substantiation.11, 14 Also, the observed relationships may be related to the size of the data set and the number of variables considered, rather than to a true effect.

The main strength of this study was that the data from which conclusions were drawn came from a large and geographically diverse patient population. However, the study also had several limitations. First, the response rate was relatively low, primarily because this study was a retrospective analysis performed using data collected for clinical and administrative reasons. Patient contact number was missing or incorrect in 16% of cases. Also, because of the narrow window of time during which the survey was administered, the call center, which was following up an average of 370 discharged patients per day, was only able to make 1 or 2 attempts to reach each patient. This contrasts with prospective research on postdischarge medication use such as the study by Forster and colleagues, in which the investigator made up to 20 attempts to reach patients at different times and on different days.11 Despite these efforts, the follow‐up rate was only 69%, underscoring the challenge of data collection in this setting.

The low response rate raises the possibility that the estimated prevalence of prescription‐related issues may be inaccurate. Although highly unlikely, if all the nonresponders had problems with their prescriptions, the true event rate would be 69.9%. Conversely, if none of the nonresponders had problems, the true event rate would be 2.3%. Given the characteristics of responders and nonresponders, however, we expect that a higher survey completion rate would have yielded similar results. Nonresponders had certain characteristics that would be expected to be associated with a higher frequency of prescription‐related issues (younger age, uninsured, covered by Medicaid), but these were balanced by others that would be expected to be associated with a lower frequency of problems (higher percentage of men, lower severity of illness, fewer medications).

Another study limitation concerns the self‐reported nature of the composite outcome variable. After reviewing the structure of the call center data, we chose this composite measure because it conceptually represented difficulties in obtaining or taking prescribed discharge medications. When we analyzed results using only the most prevalent component of this composite variable, the results were similar. However, all these findings could have been influenced by social desirability bias. Patients may have underreported not filling their discharge prescriptions and also may not acknowledged difficulties in understanding how to take the medications. We would therefore expect the true prevalence of prescription‐related concerns after hospital discharge to be higher than that found in this study.

These limitations notwithstanding, the findings from this large, multicenter study show that prescription‐related issues are common after hospital discharge and, further, that they usually take the form of not filling discharge prescriptions. The highest‐risk patients appear to be those without insurance and those covered by Medicaid or Medicare HMOs, as well as adults age 3549, patients prescribed 6 or more medications, and patients with a higher severity of illness. When preparing patients to leave the hospital, physicians and other health care providers should strive to identify financial, behavioral, and other barriers to proper medication use so that appropriate assistance or counseling may be offered prior to discharge.18, 19 Close follow‐up of patients by telephone may also be a helpful approach to promptly identifying prescription‐related issues and other problems so that providers can intervene before more serious complications arise.

The period immediately following hospital discharge is a vulnerable time for patients, who must assume responsibilities for their own care as they return home.1 The process of hospital discharge may be a rushed event, and patients often have difficulty understanding and following their postdischarge treatment plan.2, 3 Medication‐related problems after hospital discharge, which include patients not filling or refilling prescriptions,46 not understanding how to take medications,2, 3 showing discrepancies between what they are and what they should be taking,79 and having adverse drug events,1012 are a major cause of morbidity and mortality.13

According to prior studies, elderly patients and patients taking more than 5 medications are more likely to experience problems with their medications.5, 14 Adverse drug events are more common with certain high‐risk drugs, including cardiovascular agents, anticoagulants, insulin, antibiotics, and steroids.11, 14, 15 Beyond this, however, patient management of prescription medications after hospital discharge has not been well described. In particular, studies in the community setting and in the immediate postdischarge period are needed.

We conducted a large observational study of patients at 170 community hospitals in order to examine the frequency of prescription‐related issues 4872 hours after hospital discharge. These issues included problems with filling or taking medications prescribed at discharge. We hypothesized that age and number of medications would be independently associated with prescription‐related problems. We also examined the effects of other factors, including insurance type, length of stay, severity of illness (SOI), clinical diagnosis, and use of certain high‐risk drugs.

METHODS

RESULTS

In 2005, there were 104,506 eligible adult hospital discharges, corresponding to 96,179 patients. Excluding discharged patients who could not be contacted by the call center or who refused to complete the survey (n = 67,084), multiple surveys of the same patient (n = 3156), and surveys with insufficient data to determine whether there were prescription‐related issues (n = 3067) left 31,199 patients available for analysis (effective response rate 32.4%).

More than half the participants (57.0%) were women, and the mean age was 61.1 years (SD 17.8 years). The median number of discharge medications was 4 (range 128). The most frequently prescribed drugs were antibiotics and analgesics, followed by several cardiovascular drug classes (Table 1). About 60% of the primary diagnoses were of circulatory, digestive, and respiratory disorders (Table 1). Compared with nonparticipants, the study sample was more likely to be female, older, and covered by Medicare. Study patients also had greater comorbidity, as indicated by greater severity of illness rating and number of discharge medications.

Overall, 7.2% of patients (n = 2253) had prescription‐related issues 4872 hours after hospital discharge. This included not picking up prescribed discharge medications (n = 1797, or 79.8% of issues), not knowing if they were picked up (n = 55 or 2.4%), and admitting to not taking (n = 154, or 6.8%) or not understanding how to take (n = 247, or 11%) medications.

In unadjusted analyses, prescription‐related issues were significantly associated with age, sex, insurance type, severity of illness rating, length of stay, number of discharge medications, certain medication types, and major diagnostic category (Table 2). Except for the youngest patients (age < 35 years), having prescription‐related issues appeared to be inversely related to patient age. Adults 3549 years old had the highest frequency of problems filling or taking medications (9.3%), whereas patients 80 years or older had the lowest frequency (5.6%). Analysis by insurance status showed that patients with Medicaid (12.6%) or self‐pay/uninsured status (11.9%) had significantly higher rates of prescription issues and patients with non‐Medicare HMO or commercial insurance had significantly lower rates (6.1% and 4.9%, respectively). Being prescribed at least 6 medications or taking ACE inhibitors, inhalers, oral hypoglycemics, or insulins was also associated with a higher frequency of prescription‐related problems in unadjusted analyses. Patients prescribed antibiotics or anticoagulants were less likely to report problems in unadjusted analyses.

In multivariable models, age, sex, insurance type, severity of illness, number of medications, and certain medication types were independently associated with prescription‐related issues after discharge (Table 3). Seniors reported significantly fewer problems than the youngest patients (6579 years, OR 0.69; 80 years, OR 0.59). Those with Medicare HMOs, Medicaid, or no insurance had more difficulty obtaining and taking prescription medications (OR 1.29, 1.33, and 1.31, respectively), whereas patients with HMO or commercial insurance plans had less difficulty (OR 0.68 and 0.51, respectively). Prescription‐related problems were also more common among women (OR 1.11), patients with higher severity of illness (moderate SOI, OR 1.12; major/extreme SOI, OR 1.23), and those with 6 or more discharge medications (OR 1.35). In adjusted analyses, inhalers were the only type of medication associated with a significantly higher frequency of problems (OR 1.14).

Analyses were repeated using only failure to pick up medications as the dependent variable, and results were similar (not shown).

DISCUSSION

In this large multicenter study, 7.2% of patients reported problems obtaining or taking prescribed medications in the 4872 hours following hospital discharge. In about 80% of cases, the problem was failure to pick up discharge medications. Multivariable analyses showed adults 3549 years old; women; patients with Medicare HMO insurance, Medicaid, or no coverage (self‐pay); adults with high severity of illness rating; and those prescribed more than 5 medications or an inhaler had significantly greater odds of prescription‐related issues. Other factors were protective including age 65 or older; HMO or commercial insurance; prescription of antibiotics, anticoagulants, or angiotensin II receptor blockers; and major diagnosis in the skin or musculoskeletal category.

Among all the groups studied, patients with Medicaid or no insurance had the highest frequency of problems filling and taking discharge medications (12.6% and 11.9%, respectively). This was likely related to their having less prescription drug coverage or experiencing other financial constraints. In previous studies, patients have expressed concern over the rising cost of medications and have admitted to not filling prescriptions or stretching out the use of medications to make them last longer because of high out‐of‐pocket costs.5, 16 Prescriptions given at hospital discharge may pose a significant unexpected expense for patients who have a fixed monthly income, rely on samples from outpatient physicians for their medications, or need time to research cost‐saving measures such as discount plans. Greater attention by physicians to knowing the cost of discharge medications, to prescribing only those drugs that are truly necessary, and to discussing cost‐saving strategies with patients may help to minimize financial concerns and improve the ability of patients to fill discharge prescriptions.17

The finding that polypharmacy is associated with greater odds of prescription‐related issues is consistent with research that found that other medication problems such as adverse drug events and nonadherence were more prevalent among patients prescribed more than 5 medications.5, 14 Polypharmacy may have contributed to prescription‐related difficulties in this study by increasing medication costs or by increasing the chance that patients had a problem with at least 1 medication.

The higher frequency of prescription‐related issues among patients prescribed inhalers indicates that this category of medication may be associated with lower fill rates or greater confusion after discharge. This would be concerning, given that repeat exacerbations of obstructive lung disease may lead to rehospitalization. Other medications, including anticoagulants and antibiotics, were associated with a lower frequency of problems. This may have been the result of better education at discharge about the importance of promptly filling prescriptions for these agents in order to avoid a lapse in therapy following acute treatment for thromboembolic disorders or acute infections. It is hoped that a similar educational effort about filling prescriptions for inhalers also would have occurred. These effects have not been noted in prior research and require further substantiation.11, 14 Also, the observed relationships may be related to the size of the data set and the number of variables considered, rather than to a true effect.

The main strength of this study was that the data from which conclusions were drawn came from a large and geographically diverse patient population. However, the study also had several limitations. First, the response rate was relatively low, primarily because this study was a retrospective analysis performed using data collected for clinical and administrative reasons. Patient contact number was missing or incorrect in 16% of cases. Also, because of the narrow window of time during which the survey was administered, the call center, which was following up an average of 370 discharged patients per day, was only able to make 1 or 2 attempts to reach each patient. This contrasts with prospective research on postdischarge medication use such as the study by Forster and colleagues, in which the investigator made up to 20 attempts to reach patients at different times and on different days.11 Despite these efforts, the follow‐up rate was only 69%, underscoring the challenge of data collection in this setting.

The low response rate raises the possibility that the estimated prevalence of prescription‐related issues may be inaccurate. Although highly unlikely, if all the nonresponders had problems with their prescriptions, the true event rate would be 69.9%. Conversely, if none of the nonresponders had problems, the true event rate would be 2.3%. Given the characteristics of responders and nonresponders, however, we expect that a higher survey completion rate would have yielded similar results. Nonresponders had certain characteristics that would be expected to be associated with a higher frequency of prescription‐related issues (younger age, uninsured, covered by Medicaid), but these were balanced by others that would be expected to be associated with a lower frequency of problems (higher percentage of men, lower severity of illness, fewer medications).

Another study limitation concerns the self‐reported nature of the composite outcome variable. After reviewing the structure of the call center data, we chose this composite measure because it conceptually represented difficulties in obtaining or taking prescribed discharge medications. When we analyzed results using only the most prevalent component of this composite variable, the results were similar. However, all these findings could have been influenced by social desirability bias. Patients may have underreported not filling their discharge prescriptions and also may not acknowledged difficulties in understanding how to take the medications. We would therefore expect the true prevalence of prescription‐related concerns after hospital discharge to be higher than that found in this study.

These limitations notwithstanding, the findings from this large, multicenter study show that prescription‐related issues are common after hospital discharge and, further, that they usually take the form of not filling discharge prescriptions. The highest‐risk patients appear to be those without insurance and those covered by Medicaid or Medicare HMOs, as well as adults age 3549, patients prescribed 6 or more medications, and patients with a higher severity of illness. When preparing patients to leave the hospital, physicians and other health care providers should strive to identify financial, behavioral, and other barriers to proper medication use so that appropriate assistance or counseling may be offered prior to discharge.18, 19 Close follow‐up of patients by telephone may also be a helpful approach to promptly identifying prescription‐related issues and other problems so that providers can intervene before more serious complications arise.

As the counterpart to hospital admission, hospital discharge is a necessary process experienced by each living patient. For all patients except those being transferred to a continuing care facility, discharge is a period of transition from hospital to home that involves a transfer in responsibility from the inpatient provider or hospitalist to the patient and primary care physician (PCP).1 Prescription medications are commonly altered at this transition point, with patients asked to discontinue some medications, switch to a new dosage schedule of others, or begin new treatments.2, 3 Self‐care responsibilities also increase in number and importance, presenting new challenges for patients and their families as they return home.4 Under these circumstances, ineffective planning and coordination of care can undermine patient satisfaction, facilitate adverse events, and contribute to more frequent hospital readmissions.58

Following hospital discharge nearly half (49%) of hospitalized patients experience at least 1 medical error in medication continuity, diagnostic workup, or test follow‐up.7 It has been reported that 19%23% of patients suffer an adverse event, most frequently an adverse drug event (ADE).911 Half of ADEs are considered preventable or ameliorable (ie, their severity or duration could have been decreased). Most errors and adverse events in this setting result from a breakdown in communication between the hospital team and the patient or primary care physician.10

To promote more effective care transitions, The Joint Commission now requires accredited facilities to accurately and completely reconcile medications across the continuum of care.12 The Society of Hospital Medicine recently published recommendations for the discharge of elderly patients.13 The joint Society of Hospital MedicineSociety of General Internal Medicine Continuity of Care Task Force also recently published a systematic review with recommendations for improving the handoff of patient information at discharge.14 Apart from these reports, however, it is uncommon to find evidence‐based recommendations for hospital discharge applicable to a broad range of patients.15 This review highlights several important challenges for physicians who seek to provide high‐quality care during hospital discharge and the subsequent period of transition. Based on the best available evidence, recommendations are also provided for how to improve communication and facilitate the care transition for adult inpatients returning home.

INPATIENTOUTPATIENT PHYSICIAN DISCONTINUITY

Traditionally, primary care physicians have admitted their own patients, provided hospital care (in addition to seeing outpatients during the day), and followed patients after discharge. Under this model, continuity of care has been preserved; however, this method of care has faltered under the weight of inpatients and outpatients with more severe illnesses, rapid technological advancements, managed care pressuring outpatient physicians to see more patients, and a thrust toward reduced hospital costs and length of stay.16 Increases in the efficiency and quality of hospital care have accompanied a new reliance on the field of hospital medicine, while allowing PCPs to focus on outpatient care.1719 With more than 14,000 hospitalists currently practicing in the United States and 25,000 anticipated to be practicing by 2010, transfer of care from hospital‐based providers to PCPs has become increasingly common at discharge.20

Patient discharge summaries are the most common means of communication between inpatient and outpatient providers. However, numerous studies have shown that discharge summaries often fail to provide important administrative and medical information, such as the primary diagnosis, results of abnormal diagnostics, details about the hospital course, follow‐up plans, whether laboratory test results are pending, and patient or family counseling.14 Summaries also may not arrive in a timely manner and sometimes may not reach the PCP at all.2123

At the time patients first follow up with their PCPs after hospitalization, discharge summaries have not yet arrived about 75% of the time,22, 24, 25 restricting the PCPs' ability to provide adequate follow‐up care in 24% of hospital follow‐up visits, according to one study.26 In another investigation, PCPs reported being unaware of 62% of the pending test results that returned after discharge, of which 37% were considered actionable.27

CHANGES AND DISCREPANCIES IN THE MEDICATION REGIMEN

Medication errors make up a large portion of the adverse events patients may experience in the period following hospital discharge.7 In fact, errors during the ordering of admission or discharge medications make up almost half of all hospital medication errors.4043 At transition points such as admission and discharge, errors are often associated with changes in the medication regimen, including discrepancies between the new set of medication orders and what the patient was taking previously. In 2 recent studies, 54% of patients experienced at least 1 unintended medication discrepancy on admission to the hospital, and 39%‐45% of these discrepancies were considered a potential threat to the patient.44, 45

At discharge, differences between the prescribed medication regimen and the prehospital regimen may exist for several reasons. First, physicians may not obtain a comprehensive and accurate medication history at the time of admission.46 The medication history elicited from the patient at hospital admission is often affected by health literacy, language barriers, current health status, medication‐history interviewing skills, and time constraints.47 Physicians may not consult other important sources of medication information, including family members, prescription lists or bottles, and community pharmacy records. The most common error in the admission medication history is omitting a medication taken at home.46 Additionally, several providers, including a physician, a nurse, and an inpatient pharmacist, may independently take medication histories for the same patient. These multiple accounts lead to discrepancies that are rarely recognized or corrected.

Second, a patient's medication regimen can be significantly altered several times during a hospitalization. Acute illness may cause physicians to hold certain medications, discontinue others, or change prescribed doses during hospitalization.48 In addition, at most hospitals closed drug formularies necessitate automatic substitution of 1 medication for another drug in the same class during the patient's hospital stay.49 Changes from long‐acting to short‐acting medications are also routinely made in the name of tighter control (eg, of blood pressure). One study of hospitalized elders found that 40% of all admission medications had been discontinued by discharge and that 45% of all discharge medications were newly started during the hospitalization.3

Finally, at discharge, the current medication regimen needs to be reconciled with the preadmission medication regimen in a thoughtful manner.2 This includes resuming medications held or modified at admission for clinical reasons, resuming medications that were substituted in the hospital for formulary or pharmacokinetic reasons, and stopping newly started medications that were only required during the hospitalization (eg, for prevention of venous thromboembolism or stress ulcers).50 It is difficult, even in hospitals with advanced electronic health information systems, to prompt physicians to make these necessary changes. In a recent study, unexplained discrepancies between the preadmission medication list and discharge medication orders were noted in 49% of hospital discharges.51 Errors in discharge medication reconciliation may subsequently increase the risk of postdischarge ADEs.51

SELF‐CARE RESPONSIBILITIES AND SOCIAL SUPPORT

Compounding the difficulties at discharge are the economic pressures on our health care system, causing patients to be released from the hospital quicker and sicker than ever before.68 The scope of care provided to patients also undergoes a major shift at discharge. Multidisciplinary providers no longer continually review the health status and needs of patients; instead, patients must follow up with their outpatient physician over a period of days to weeks. In the interim, the patients themselves are responsible for administering new medications, participating in physical therapy, and tracking their own symptoms to see if they are worsening. For many patients, sufficient social and family support is not available to help perform these activities effectively. Unfortunately, hospital personnel often inaccurately assess patients' functional status and overestimate patients' knowledge of required self‐care activities.69

INEFFECTIVE PHYSICIANPATIENT COMMUNICATION

Physicianpatient communication is fundamental to the practice of medicine and is crucially important at discharge. However, several studies have demonstrated a disconnect between physician information giving and patient understanding.76, 9690 When providing instructions, physicians commonly use medical jargon and attempt to cover a wealth of information in a limited amount of time.69, 87 They also tend to rely on verbal instructions and fail to provide supplementary audiovisual materials (eg, educational handouts or videos) that could aid patient comprehension. Physicians may not point out important self‐care tasks that patients should carry out at home. The entire interaction may be rushed or seem rushed. Moreover, when physicians solicit questions from patients, they may only allow for yes/no responses by using statements like Any questions? or Do you have any questions? that make it easy for patients to simply respond, No. The encounter usually comes to an end without true confirmation of a patient's level of understanding or assessment of a patient's ability to perform the self‐care activities and medication management required on returning home.81

Adding to the challenges of effective physicianpatient communication is the large number of adult Americans (more than 90 million) who have limited functional literacy skills.91, 92 Such patients typically have difficulty reading and understanding medical instructions, medication labels, and appointment slips.9396 Not surprisingly, patients with limited literacy skills know less about their chronic illnesses and how to manage their diseases.97 Having low literacy is also linked to increased use of emergency department services, a higher risk of hospitalization, and higher health care costs.9799 Patients with limited English proficiency have similar or even greater challenges and also have longer stays in the hospital.100

CONCLUSIONS

The transition from hospital to home is a vulnerable period of discontinuity and potential adverse events. Hospitalists and other inpatient providers should not view discharge as an end to their obligation to patients but rather should attempt to promote a safe and efficient transition of care. Hospitalists can play an important role in bridging the gap between inpatient and outpatient care through appropriate discharge planning and effective communication with patients, their family members, and outpatient physicians.

As the counterpart to hospital admission, hospital discharge is a necessary process experienced by each living patient. For all patients except those being transferred to a continuing care facility, discharge is a period of transition from hospital to home that involves a transfer in responsibility from the inpatient provider or hospitalist to the patient and primary care physician (PCP).1 Prescription medications are commonly altered at this transition point, with patients asked to discontinue some medications, switch to a new dosage schedule of others, or begin new treatments.2, 3 Self‐care responsibilities also increase in number and importance, presenting new challenges for patients and their families as they return home.4 Under these circumstances, ineffective planning and coordination of care can undermine patient satisfaction, facilitate adverse events, and contribute to more frequent hospital readmissions.58

Following hospital discharge nearly half (49%) of hospitalized patients experience at least 1 medical error in medication continuity, diagnostic workup, or test follow‐up.7 It has been reported that 19%23% of patients suffer an adverse event, most frequently an adverse drug event (ADE).911 Half of ADEs are considered preventable or ameliorable (ie, their severity or duration could have been decreased). Most errors and adverse events in this setting result from a breakdown in communication between the hospital team and the patient or primary care physician.10

To promote more effective care transitions, The Joint Commission now requires accredited facilities to accurately and completely reconcile medications across the continuum of care.12 The Society of Hospital Medicine recently published recommendations for the discharge of elderly patients.13 The joint Society of Hospital MedicineSociety of General Internal Medicine Continuity of Care Task Force also recently published a systematic review with recommendations for improving the handoff of patient information at discharge.14 Apart from these reports, however, it is uncommon to find evidence‐based recommendations for hospital discharge applicable to a broad range of patients.15 This review highlights several important challenges for physicians who seek to provide high‐quality care during hospital discharge and the subsequent period of transition. Based on the best available evidence, recommendations are also provided for how to improve communication and facilitate the care transition for adult inpatients returning home.

INPATIENTOUTPATIENT PHYSICIAN DISCONTINUITY

Traditionally, primary care physicians have admitted their own patients, provided hospital care (in addition to seeing outpatients during the day), and followed patients after discharge. Under this model, continuity of care has been preserved; however, this method of care has faltered under the weight of inpatients and outpatients with more severe illnesses, rapid technological advancements, managed care pressuring outpatient physicians to see more patients, and a thrust toward reduced hospital costs and length of stay.16 Increases in the efficiency and quality of hospital care have accompanied a new reliance on the field of hospital medicine, while allowing PCPs to focus on outpatient care.1719 With more than 14,000 hospitalists currently practicing in the United States and 25,000 anticipated to be practicing by 2010, transfer of care from hospital‐based providers to PCPs has become increasingly common at discharge.20

Patient discharge summaries are the most common means of communication between inpatient and outpatient providers. However, numerous studies have shown that discharge summaries often fail to provide important administrative and medical information, such as the primary diagnosis, results of abnormal diagnostics, details about the hospital course, follow‐up plans, whether laboratory test results are pending, and patient or family counseling.14 Summaries also may not arrive in a timely manner and sometimes may not reach the PCP at all.2123

At the time patients first follow up with their PCPs after hospitalization, discharge summaries have not yet arrived about 75% of the time,22, 24, 25 restricting the PCPs' ability to provide adequate follow‐up care in 24% of hospital follow‐up visits, according to one study.26 In another investigation, PCPs reported being unaware of 62% of the pending test results that returned after discharge, of which 37% were considered actionable.27

CHANGES AND DISCREPANCIES IN THE MEDICATION REGIMEN

Medication errors make up a large portion of the adverse events patients may experience in the period following hospital discharge.7 In fact, errors during the ordering of admission or discharge medications make up almost half of all hospital medication errors.4043 At transition points such as admission and discharge, errors are often associated with changes in the medication regimen, including discrepancies between the new set of medication orders and what the patient was taking previously. In 2 recent studies, 54% of patients experienced at least 1 unintended medication discrepancy on admission to the hospital, and 39%‐45% of these discrepancies were considered a potential threat to the patient.44, 45

At discharge, differences between the prescribed medication regimen and the prehospital regimen may exist for several reasons. First, physicians may not obtain a comprehensive and accurate medication history at the time of admission.46 The medication history elicited from the patient at hospital admission is often affected by health literacy, language barriers, current health status, medication‐history interviewing skills, and time constraints.47 Physicians may not consult other important sources of medication information, including family members, prescription lists or bottles, and community pharmacy records. The most common error in the admission medication history is omitting a medication taken at home.46 Additionally, several providers, including a physician, a nurse, and an inpatient pharmacist, may independently take medication histories for the same patient. These multiple accounts lead to discrepancies that are rarely recognized or corrected.

Second, a patient's medication regimen can be significantly altered several times during a hospitalization. Acute illness may cause physicians to hold certain medications, discontinue others, or change prescribed doses during hospitalization.48 In addition, at most hospitals closed drug formularies necessitate automatic substitution of 1 medication for another drug in the same class during the patient's hospital stay.49 Changes from long‐acting to short‐acting medications are also routinely made in the name of tighter control (eg, of blood pressure). One study of hospitalized elders found that 40% of all admission medications had been discontinued by discharge and that 45% of all discharge medications were newly started during the hospitalization.3

Finally, at discharge, the current medication regimen needs to be reconciled with the preadmission medication regimen in a thoughtful manner.2 This includes resuming medications held or modified at admission for clinical reasons, resuming medications that were substituted in the hospital for formulary or pharmacokinetic reasons, and stopping newly started medications that were only required during the hospitalization (eg, for prevention of venous thromboembolism or stress ulcers).50 It is difficult, even in hospitals with advanced electronic health information systems, to prompt physicians to make these necessary changes. In a recent study, unexplained discrepancies between the preadmission medication list and discharge medication orders were noted in 49% of hospital discharges.51 Errors in discharge medication reconciliation may subsequently increase the risk of postdischarge ADEs.51

SELF‐CARE RESPONSIBILITIES AND SOCIAL SUPPORT

Compounding the difficulties at discharge are the economic pressures on our health care system, causing patients to be released from the hospital quicker and sicker than ever before.68 The scope of care provided to patients also undergoes a major shift at discharge. Multidisciplinary providers no longer continually review the health status and needs of patients; instead, patients must follow up with their outpatient physician over a period of days to weeks. In the interim, the patients themselves are responsible for administering new medications, participating in physical therapy, and tracking their own symptoms to see if they are worsening. For many patients, sufficient social and family support is not available to help perform these activities effectively. Unfortunately, hospital personnel often inaccurately assess patients' functional status and overestimate patients' knowledge of required self‐care activities.69

INEFFECTIVE PHYSICIANPATIENT COMMUNICATION

Physicianpatient communication is fundamental to the practice of medicine and is crucially important at discharge. However, several studies have demonstrated a disconnect between physician information giving and patient understanding.76, 9690 When providing instructions, physicians commonly use medical jargon and attempt to cover a wealth of information in a limited amount of time.69, 87 They also tend to rely on verbal instructions and fail to provide supplementary audiovisual materials (eg, educational handouts or videos) that could aid patient comprehension. Physicians may not point out important self‐care tasks that patients should carry out at home. The entire interaction may be rushed or seem rushed. Moreover, when physicians solicit questions from patients, they may only allow for yes/no responses by using statements like Any questions? or Do you have any questions? that make it easy for patients to simply respond, No. The encounter usually comes to an end without true confirmation of a patient's level of understanding or assessment of a patient's ability to perform the self‐care activities and medication management required on returning home.81

Adding to the challenges of effective physicianpatient communication is the large number of adult Americans (more than 90 million) who have limited functional literacy skills.91, 92 Such patients typically have difficulty reading and understanding medical instructions, medication labels, and appointment slips.9396 Not surprisingly, patients with limited literacy skills know less about their chronic illnesses and how to manage their diseases.97 Having low literacy is also linked to increased use of emergency department services, a higher risk of hospitalization, and higher health care costs.9799 Patients with limited English proficiency have similar or even greater challenges and also have longer stays in the hospital.100

CONCLUSIONS

The transition from hospital to home is a vulnerable period of discontinuity and potential adverse events. Hospitalists and other inpatient providers should not view discharge as an end to their obligation to patients but rather should attempt to promote a safe and efficient transition of care. Hospitalists can play an important role in bridging the gap between inpatient and outpatient care through appropriate discharge planning and effective communication with patients, their family members, and outpatient physicians.

As the counterpart to hospital admission, hospital discharge is a necessary process experienced by each living patient. For all patients except those being transferred to a continuing care facility, discharge is a period of transition from hospital to home that involves a transfer in responsibility from the inpatient provider or hospitalist to the patient and primary care physician (PCP).1 Prescription medications are commonly altered at this transition point, with patients asked to discontinue some medications, switch to a new dosage schedule of others, or begin new treatments.2, 3 Self‐care responsibilities also increase in number and importance, presenting new challenges for patients and their families as they return home.4 Under these circumstances, ineffective planning and coordination of care can undermine patient satisfaction, facilitate adverse events, and contribute to more frequent hospital readmissions.58

Following hospital discharge nearly half (49%) of hospitalized patients experience at least 1 medical error in medication continuity, diagnostic workup, or test follow‐up.7 It has been reported that 19%23% of patients suffer an adverse event, most frequently an adverse drug event (ADE).911 Half of ADEs are considered preventable or ameliorable (ie, their severity or duration could have been decreased). Most errors and adverse events in this setting result from a breakdown in communication between the hospital team and the patient or primary care physician.10

To promote more effective care transitions, The Joint Commission now requires accredited facilities to accurately and completely reconcile medications across the continuum of care.12 The Society of Hospital Medicine recently published recommendations for the discharge of elderly patients.13 The joint Society of Hospital MedicineSociety of General Internal Medicine Continuity of Care Task Force also recently published a systematic review with recommendations for improving the handoff of patient information at discharge.14 Apart from these reports, however, it is uncommon to find evidence‐based recommendations for hospital discharge applicable to a broad range of patients.15 This review highlights several important challenges for physicians who seek to provide high‐quality care during hospital discharge and the subsequent period of transition. Based on the best available evidence, recommendations are also provided for how to improve communication and facilitate the care transition for adult inpatients returning home.

INPATIENTOUTPATIENT PHYSICIAN DISCONTINUITY

Traditionally, primary care physicians have admitted their own patients, provided hospital care (in addition to seeing outpatients during the day), and followed patients after discharge. Under this model, continuity of care has been preserved; however, this method of care has faltered under the weight of inpatients and outpatients with more severe illnesses, rapid technological advancements, managed care pressuring outpatient physicians to see more patients, and a thrust toward reduced hospital costs and length of stay.16 Increases in the efficiency and quality of hospital care have accompanied a new reliance on the field of hospital medicine, while allowing PCPs to focus on outpatient care.1719 With more than 14,000 hospitalists currently practicing in the United States and 25,000 anticipated to be practicing by 2010, transfer of care from hospital‐based providers to PCPs has become increasingly common at discharge.20

Patient discharge summaries are the most common means of communication between inpatient and outpatient providers. However, numerous studies have shown that discharge summaries often fail to provide important administrative and medical information, such as the primary diagnosis, results of abnormal diagnostics, details about the hospital course, follow‐up plans, whether laboratory test results are pending, and patient or family counseling.14 Summaries also may not arrive in a timely manner and sometimes may not reach the PCP at all.2123

At the time patients first follow up with their PCPs after hospitalization, discharge summaries have not yet arrived about 75% of the time,22, 24, 25 restricting the PCPs' ability to provide adequate follow‐up care in 24% of hospital follow‐up visits, according to one study.26 In another investigation, PCPs reported being unaware of 62% of the pending test results that returned after discharge, of which 37% were considered actionable.27

CHANGES AND DISCREPANCIES IN THE MEDICATION REGIMEN

Medication errors make up a large portion of the adverse events patients may experience in the period following hospital discharge.7 In fact, errors during the ordering of admission or discharge medications make up almost half of all hospital medication errors.4043 At transition points such as admission and discharge, errors are often associated with changes in the medication regimen, including discrepancies between the new set of medication orders and what the patient was taking previously. In 2 recent studies, 54% of patients experienced at least 1 unintended medication discrepancy on admission to the hospital, and 39%‐45% of these discrepancies were considered a potential threat to the patient.44, 45

At discharge, differences between the prescribed medication regimen and the prehospital regimen may exist for several reasons. First, physicians may not obtain a comprehensive and accurate medication history at the time of admission.46 The medication history elicited from the patient at hospital admission is often affected by health literacy, language barriers, current health status, medication‐history interviewing skills, and time constraints.47 Physicians may not consult other important sources of medication information, including family members, prescription lists or bottles, and community pharmacy records. The most common error in the admission medication history is omitting a medication taken at home.46 Additionally, several providers, including a physician, a nurse, and an inpatient pharmacist, may independently take medication histories for the same patient. These multiple accounts lead to discrepancies that are rarely recognized or corrected.

Second, a patient's medication regimen can be significantly altered several times during a hospitalization. Acute illness may cause physicians to hold certain medications, discontinue others, or change prescribed doses during hospitalization.48 In addition, at most hospitals closed drug formularies necessitate automatic substitution of 1 medication for another drug in the same class during the patient's hospital stay.49 Changes from long‐acting to short‐acting medications are also routinely made in the name of tighter control (eg, of blood pressure). One study of hospitalized elders found that 40% of all admission medications had been discontinued by discharge and that 45% of all discharge medications were newly started during the hospitalization.3

Finally, at discharge, the current medication regimen needs to be reconciled with the preadmission medication regimen in a thoughtful manner.2 This includes resuming medications held or modified at admission for clinical reasons, resuming medications that were substituted in the hospital for formulary or pharmacokinetic reasons, and stopping newly started medications that were only required during the hospitalization (eg, for prevention of venous thromboembolism or stress ulcers).50 It is difficult, even in hospitals with advanced electronic health information systems, to prompt physicians to make these necessary changes. In a recent study, unexplained discrepancies between the preadmission medication list and discharge medication orders were noted in 49% of hospital discharges.51 Errors in discharge medication reconciliation may subsequently increase the risk of postdischarge ADEs.51

SELF‐CARE RESPONSIBILITIES AND SOCIAL SUPPORT

Compounding the difficulties at discharge are the economic pressures on our health care system, causing patients to be released from the hospital quicker and sicker than ever before.68 The scope of care provided to patients also undergoes a major shift at discharge. Multidisciplinary providers no longer continually review the health status and needs of patients; instead, patients must follow up with their outpatient physician over a period of days to weeks. In the interim, the patients themselves are responsible for administering new medications, participating in physical therapy, and tracking their own symptoms to see if they are worsening. For many patients, sufficient social and family support is not available to help perform these activities effectively. Unfortunately, hospital personnel often inaccurately assess patients' functional status and overestimate patients' knowledge of required self‐care activities.69

INEFFECTIVE PHYSICIANPATIENT COMMUNICATION

Physicianpatient communication is fundamental to the practice of medicine and is crucially important at discharge. However, several studies have demonstrated a disconnect between physician information giving and patient understanding.76, 9690 When providing instructions, physicians commonly use medical jargon and attempt to cover a wealth of information in a limited amount of time.69, 87 They also tend to rely on verbal instructions and fail to provide supplementary audiovisual materials (eg, educational handouts or videos) that could aid patient comprehension. Physicians may not point out important self‐care tasks that patients should carry out at home. The entire interaction may be rushed or seem rushed. Moreover, when physicians solicit questions from patients, they may only allow for yes/no responses by using statements like Any questions? or Do you have any questions? that make it easy for patients to simply respond, No. The encounter usually comes to an end without true confirmation of a patient's level of understanding or assessment of a patient's ability to perform the self‐care activities and medication management required on returning home.81

Adding to the challenges of effective physicianpatient communication is the large number of adult Americans (more than 90 million) who have limited functional literacy skills.91, 92 Such patients typically have difficulty reading and understanding medical instructions, medication labels, and appointment slips.9396 Not surprisingly, patients with limited literacy skills know less about their chronic illnesses and how to manage their diseases.97 Having low literacy is also linked to increased use of emergency department services, a higher risk of hospitalization, and higher health care costs.9799 Patients with limited English proficiency have similar or even greater challenges and also have longer stays in the hospital.100

CONCLUSIONS

The transition from hospital to home is a vulnerable period of discontinuity and potential adverse events. Hospitalists and other inpatient providers should not view discharge as an end to their obligation to patients but rather should attempt to promote a safe and efficient transition of care. Hospitalists can play an important role in bridging the gap between inpatient and outpatient care through appropriate discharge planning and effective communication with patients, their family members, and outpatient physicians.

There is a growing demand for hospitalists in the United States. In academic settings, hospitalists are called on to perform a variety of duties, from leading quality improvement initiatives to serving on hospital committees to helping to offset restrictions on work hours of the house staff.1 Although hospitalists may be well positioned to take on these roles, obtaining adequate protected time and recognition for such contributions remains a challenge. The existing promotion and tenure processes at academic institutions may not give adequate consideration to such responsibilities. Hospitalists who do not meet the traditional benchmarks of teaching and research may suffer in their career advancement and, ultimately, in their desire to remain in academics. Developing a sustainable and long‐term career in hospital medicine is important not only from a professional developmental standpoint, but also because it may lead to better patient care; evidence from a large multicenter hospitalist study suggests that physician experience is linked to improved patient care and outcomes.2 Thus, it behooves academic medical centers that employ hospitalists to create rewarding hospitalist career paths.

Goldman described academic hospital medicine as comprising periods of systole, during which hospitalists provide clinical care, and periods of diastole, the portion of a hospitalist's time spent in nonclinical activities.3 Far from being a period of relaxation, diastole is an active component of a hospitalist's work, the time devoted to the pursuit of complementary interests, career advancement, and job diversity. A well‐thought‐out plan for the diastolic phase of a hospitalist job description can lead to significant improvement in quality, education, research, and outcomes for an academic medical center.4 A good balance of systole and diastole allows for focus on career development and advancement and has the potential to be very helpful in preventing burnout. This is of particular concern to academic hospitalists, who report working longer hours, feeling more stress, and worrying more about burnout than their nonhospitalist colleagues.5 This suggests the diastolic phase is an important part of creating a sustainable hospitalist job and should be funded as part of an academic hospitalist position.

Although the optimal balance of systole and diastole to prevent burnout is not known, outlining clear expectations is an important strategy for preparing physicians for a sustainable academic hospitalist career. This is an important issue, given the increasing number of residency graduates who are choosing careers in hospital medicine.6 Based on the reported career plans of residents taking internal medicine in‐training exams from 2002 through 2006, the number of residents going into hospital medicine has more than doubled, from 3% (in 2002) to 6.5% (in 2006). The goal of this article is to compare and contrast several career paths that balance systole and diastole in academic hospital medicine. Specifically, we review training opportunities for becoming a successful hospitalist‐educator, hospitalistquality expert, hospitalist‐investigator, and hospitalist‐administrator.

EDUCATION (THE HOSPITALIST‐EDUCATOR)

Hospitalists in academic centers often play central roles as teachers and leaders in medical education. This is not surprising given that most teaching of medical trainees occurs in the inpatient setting.7 Furthermore, several studies have consistently demonstrated that trainee satisfaction with teaching by hospitalists is high, and hospitalists are rated as more effective teachers than traditional subspecialist ward attendings.810

A typical hospitalist‐educator position is 80%‐90% clinical time, with 10%‐20% set aside for teaching. However, academic hospitalists are often expected to teach medical trainees concurrently with their clinical care activities, rather than during a separate, protected time.11 Thus, most hospitalist‐educator responsibilities do not occur during diastole, as may be conceived, but instead are add to the systole. Small amounts of protected diastolic time for a hospitalist‐educator can be used for related administrative activities, such as writing letters of recommendation, mentoring students and residents, doing creative thinking and curriculum development, and conducting educational research, such as evaluating a new educational program or curriculum. Some hospitalist‐educator positions, such as director of the residency program or internal medicine clerkship, are exceptions in that they generally include a greater amount of protected time, which may be earmarked for administrative activities and hands‐on teaching.

CLINICAL QUALITY AND OPERATIONS IMPROVEMENT (THE HOSPITALISTQUALITY EXPERT)

Hospitalists are increasingly being called on to lead clinical quality and operations improvement at academic teaching hospitals. Benefits to the institution include the consistent presence of a committed physician who is able to plan and execute change in the context of clinical care. This is in contrast to the transient nature of residents and nonhospitalist attending physicians, whose ability to participate in such initiatives is impaired by the scheduling of their rotations. Hospitalists, however, are often able to cultivate long‐standing relationships with nurses, case managers, and hospital administrators, thereby building the institutional clout to lead such initiatives while considering views from all the necessary stakeholders.22 Thus, they are in a good position to serve as physician champions and expedite the adoption of new innovations within hospitalist groups and among other physician groups and clinical staff.23, 24

RESEARCH (THE HOSPITALIST‐INVESTIGATOR)

Few hospitalists devote most of their time to clinical research. Having a strong research base is essential for the field of hospital medicine to gain credibility as a distinct specialty.4 Although the initial research in hospital medicine sought to prove the value of the field itself, hospitalists have now begun to focus on quality improvement and outcomes research.3032 Because of their unique position in clinical care, hospitalists are well situated to oversee inpatient data collection and perform research on a variety of conditions ranging from acute coronary syndromes to venous thromboembolism. Another potential area of research for hospitalists is participation in clinical trials focused on the inpatient setting. Although the proportion of time spent in research can vary widely, to become an independently successful clinical researcher typically requires a substantial amount of time be devoted to research. In general, at least 50% protected time, greater if possible, is recommended.

ADMINISTRATION (THE HOSPITALIST‐ADMINISTRATOR)

Physician leaders in hospital administration are not new. Many hospitals already include physicians in senior management positions, such as chief medical officer.44 Naturally, a career in hospital administration is another potential path for diastole in academic medical centers.

CONCLUSIONS

As hospital medicine continues to grow and evolve, designing sustainable and rewarding academic careers will be crucial to the success of the field. Being able to balance clinical systole time with obtaining the skills to support nonclinical diastole time is important to ensuring a successful career as an academic hospitalist. We have described several possible career paths in teaching, research, quality improvement, and administration. By preparing future hospitalists with the knowledge and skills required to assume a variety of roles during their diastolic time, we hope to encourage the growth of hospitalist leaders with well‐developed skill sets. If hospitalists adequately prepare themselves, academic hospital medicine will likely remain sustainable and rewarding, and future generations of trainees will be inspired and prepared to enter the field.