Family Practice Vol. 17, No. 3, 268-271
© Oxford University Press 2000
Hospitals do not inform GPs about medication that should be monitored
Hillhead Family Practice, 33 Stewartstown Road, Belfast BT11 9FZ;
a also at Institute of Postgraduate Medicine and Health Science, University of Ulster, Jordanstown BT37 0QB, UK.
Domhnall MacAuley.
Corry M, Bonner G, McEntee S, Dugan J and MacAuley D. Hospitals do not inform GPs about medication that should be monitored. Family Practice 2000, 17: 268–271.
Received 10 June 1999; Revised 5 November 1999; Accepted 21 December 1999.
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Abstract |
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Background. General practitioners are now asked to prescribe drugs that, due to possible risks and side effects, had previously been prescribed almost exclusively at hospital.
Objective. To assess the quality of hospital letters as the key communication between hospitals and GPs.
Method. Hospital letters examined using a predetermined protocol.
Results. Of 224 patients identified who were taking drugs that required regular monitoring, 173 were commenced in hospital. Fewer than one in five (30; 17%) hospital letters indicated that there was a risk associated with the drug or that it should be routinely monitored. Monitoring frequency was identified on only 14 occasions and the majority of letters (129; 74.6%) did not state who was to be responsible for ongoing monitoring (either GP or hospital). Information was slow to arrive at the practice and, in 12% of cases, the hospital letter had not arrived within 14 days of commencement of medication.
Conclusion. The information provided in hospital letters is insufficient to allow GPs to put structures in place to monitor drug therapy.
Keywords. Communication, family doctors, hospital, letters.
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Introduction |
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Medical care in chronic illness is moving increasingly from secondary to primary care. GPs are now asked to monitor drugs that had, until now, been prescribed almost exclusively by hospitals. Some of these drugs require close monitoring because of possible risks and side effects. Many drugs initiated in practice require close supervision, yet the quality of monitoring may be less than ideal1 and, in one study,2 medication misadventure caused 1.7% of visits to an emergency department.
When drugs are commenced in hospital, these patients are expected to be followed up by their GP. Good communication between hospital and general practice is essential. Letters sent to the practice when a patient attends out-patients or following admission are often the only means of informing a GP about new prescriptions and their importance.
The Northern Ireland Regional Drugs and Poisons Information Service issued guidelines to clinicians3 for good practice in monitoring 19 drugs. In response, we set out to assess the quality of care, and factors limiting implementation in our practice. Our overall aim was to explore factors associated with monitoring drug treatment in practice, and the specific objective of this study was to assess the quality of hospital letters as the key communication between hospitals and GPs.
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Methods |
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To identify patients currently taking drugs that should be monitored, the practice pharmacist searched the practice computerized repeat prescribing system using both the generic and proprietary names of the 19 drugs on the recommended list (Table 1
). The practice, a four doctor fund-holding practice in West Belfast, uses the EMIS system for all consultations and routine prescribing for a total list of 8000 patients, and we believe that we identified all relevant patients using the computer system. The practice pharmacist is employed for 1.5 days per week to advise and monitor prescribing. We did not include angiotensin-converting enzyme inhibitors and diuretics, as these drugs are now commenced routinely in practice.
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Each letter was examined by a single assessor, the practice pharmacist, using a predetermined protocol. This protocol was based on the criteria suggested in the guidelines together with factors that we believed were important in helping us monitor care. We discussed this protocol among the four partners and practice pharmacist and piloted it in a subsample. We examined each record to establish who commenced the medication and when. If the drug had been commenced at hospital, we recorded the level of seniority of the consulting doctor. We searched specifically to see if the letter included an indication of the risks associated with the drug, if explicit instructions had been given on the need for drug monitoring and if monitoring was to be undertaken at the practice or at the hospital. We also searched for some indication that the patient had been told of the risks of the drug and the necessity for drug monitoring. All hospital letters are dated on the day they arrive at the practice so we could determine the delay between attendance at the out-patient clinic or hospital discharge and receipt of the hospital letter.
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Results |
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There were 224 patients in the practice (practice list size 8500) who currently were prescribed one of the drugs listed (Table 1
). Of these, 173 patients (77.2%) had their drugs initiated at hospital and 51 patients were first prescribed these drugs at the practice. Fewer than one in five hospital letters (30; 17%) indicated that there was a risk associated with the drug prescribed (Table 2). A similar number (30; 17%) indicated that there should be regular drug monitoring, but monitoring frequency was identified on only 14 occasions and the majority of letters (129; 74.6%) did not state who was to be responsible for ongoing monitoring (either GP or hospital). In only eight letters was there an indication that the patient had been informed of a possible risk of their medication, and only nine letters stated that the patient had been informed that monitoring was necessary. Only three hospital letters mentioned guidelines for monitoring. In most cases, the medication was prescribed by junior staff (Table 3). Information was slow to arrive at the practice, and in 12% of cases the hospital letter had not arrived within 14 days of commencement of medication (Table 4).
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Discussion |
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Good patient care is a partnership between hospital and general practice, but good partnerships are built on communication. If only 17% of letters indicate that a drug could be potentially dangerous and suggest monitoring, it is very difficult for the GP to put protocols in place to monitor problems. In one study, 96% of GPs and 94% of community pharmacists said that they would like better quality of information on medication changes.4
Hospitals often change drug treatment either at out-patient clinics or on admission, and both GPs and pharmacists struggle to keep up to date with these changes. Indeed, in a study of hospital-initiated medication changes, GPs received detailed information about drug change in only five of the 130 hospital discharge letters.5 If a drug is to be monitored in hospital, this may be less important, but three-quarters of all letters gave no indication of who was responsible for ongoing monitoring.
Patients should also be involved in the decision-making and monitoring process, but hospital letters indicated that only 5% of patients had been informed of a possible drug risk and the need for monitoring. It is possible that patients may have been told but that it had not been recorded in the letter. Patients are interested in knowing more about their prescriptions and, in one study,6 conducted at a hospital out-patients, 93% of patients expressed an interest in having more information about their medication. The authors suggested that patients be given a copy of the GP letter. If there is a delay in contacting the GP, it is almost impossible for a GP to know how to proceed, and in 12% of cases the hospital letter had not arrived within 14 days of commencement of medication. It appears that little has changed in 13 years.7 The perceived importance of adequate communication may be related to the seniority of the doctor and, in most cases, medications had been commenced by doctors below the level of consultant, senior registrar, registrar or staff grade.
This very simple methodology has limitations and reflects the findings in one practice in one geographical area. Because of the location of the practice, our patients attend three major teaching hospitals serving most of the city of Belfast, and this study reflects the content of letters from these hospitals. It is also a quantitative study and, an additional qualitative component may help convey the other dynamics of communication. This study could, however, be replicated in many computerized practices, and the implications, if generalizable, are of considerable importance. This pattern is likely to be reflected nationally, and there is evidence of communication difficulties relating to prescribing internationally.8
How could we improve communication? To suggest that hospital doctors learn more about the importance of the hospital letter is perhaps too simplistic. Letters are written by many different doctors across every speciality. A more practical solution may be to suggest a structured letter format, and it may be possible for larger groups of GPs (for example in a PCG) to exert pressure on hospitals to adopt such a format. Alternatively, patients could become more involved in the communication process using patient-held records similar to those used in antenatal care.
In summary, many of these medications would have been prescribed and monitored at hospital out-patient clinics in the past. The expectation now is that patients will be followed-up in the community, but the information provided in hospital letters is insufficient to allow GPs to put structures in place to monitor drug therapy.
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References |
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1 Kalra PA, Kumwenda M, MacDowall P, Roland MO. Questionnaire study and the audit of use of angiotensin converting enzyme inhibitor and monitoring in general practice: the need for guidelines to prevent renal failure. Br Med J 1999; 318: 234–237.
2 Schneitman-McIntire O, Farnen TA, Gordon N, Chan J, Toy WA. Medication misadventures resulting in emergency department visits at an HMO medical centre. Am J Health-Syst Pharm 1996; 53: 1416–1422.
3 Drug Data. Northern Ireland Regional Drug and Poisons Service. The Royal Hospitals. 1998; 46.
4 Munday A, Kelly B, Forrester JW, Timoney A, McGovern E. Do general practitioners and community pharmacists want information on the reasons for drug therapy changes implemented by secondary care? Br J Gen Pract 1997; 47: 563–566.[Web of Science][Medline]
5 Himmel W, Tabache M, Kochen M. What happens to long-term medication when general practice patients are referred to hospital? Eur J Clin Pharmacol 1996; 50: 253–257.[Web of Science][Medline]
6 Eaden JA, Ward B, Smith H, Mayberry JF. Are we telling patients enough? A pilot study to assess patient information needs in a gastroenterology outpatient department. Eur J Gastroenterol Hepatol 1998; 10: 63–67.[Web of Science][Medline]
7 Mageean RJ. Study of ‘discharge communications' from hospital. Br Med J 1986; 293: 1283–1284.
8 Himmel W, Kocken M. Reasons for drug changes implemented by secondary care. Br J Gen Pract 1997; 47: 839.[Web of Science][Medline]
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