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Use of a Dermatology-Specific Discharge Form to Improve Outpatient Follow-up after Inpatient Dermatology Consultation
Journal Pre-proof Use of a Dermatology-Specific Discharge Form to Improve Outpatient Follow-up after Inpatient Dermatology Consultation Alyssa Miceli, DO, Karthik Krishnamurthy, DO PII:
S0190-9622(20)30141-9
DOI:
https://doi.org/10.1016/j.jaad.2020.01.057
Reference:
YMJD 14190
To appear in:
Journal of the American Academy of Dermatology
Received Date: 16 May 2019 Revised Date:
5 January 2020
Accepted Date: 11 January 2020
Please cite this article as: Miceli A, Krishnamurthy K, Use of a Dermatology-Specific Discharge Form to Improve Outpatient Follow-up after Inpatient Dermatology Consultation, Journal of the American Academy of Dermatology (2020), doi: https://doi.org/10.1016/j.jaad.2020.01.057. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier on behalf of the American Academy of Dermatology, Inc.
1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
Article type: Research Letter Title: Use of a Dermatology-Specific Discharge Form to Improve Outpatient Follow-up after Inpatient Dermatology Consultation Alyssa Miceli, DO1, Karthik Krishnamurthy, DO1 1
Orange Park Medical Center, 906 Park Avenue, Orange Park, FL 32073
Corresponding author: Alyssa Miceli, DO 906 Park Avenue Orange Park, FL 32073 Email: [email protected] Funding sources: American Academy of Dermatology’s Patient Safety and Quality Committee Resident and Fellow Quality Improvement Project Award Conflicts of Interest: None declared. Prior Presentation: Preliminary data presented at the American Academy of Dermatology 2017 Annual Meeting, Orlando, FL. Reprint requests: Alyssa Miceli, DO Manuscript word count: 550 words [excluding references, figures, and tables] Capsule summary word count: N/A References: 4 Figures: 0 Tables: 2 Supplementary Figures: 1 (DOI: 10.17632/hdwswgb23g.2) Attachments: Submission Checklist Keywords: quality improvement; consultations; dermatology; continuity of care; discharge form; outpatient follow-up
2
37
Inpatient dermatology consultations have been shown to be associated with decreased 1-year
38
readmission rates for patients with inflammatory skin conditions.1 We anecdotally identified non-
39
compliance with post-discharge follow-up appointments with consulting dermatologists as a cause of
40
poor outcomes among patients hospitalized for inflammatory skin conditions. To address this area of
41
unmet need, we performed a resident-led quality-improvement project that assessed the effect of
42
implementing a dermatology-specific discharge form on compliance with post-discharge dermatology
43
appointments.
44
Dermatology consult patients who were previously noncompliant with post-discharge
45
appointments were contacted via telephone to identify barriers to follow-up. Some reasons reported
46
included lack of understanding of their inpatient skin diagnoses and the need for long-term outpatient
47
management, discontinuation of the inpatient dermatologic treatment regimen upon discharge, and
48
confusion about how and where to follow-up. Many patients believed that they only needed to follow-up
49
with their primary care physician, suggesting suboptimal communication regarding dermatologic care
50
upon hospital discharge.
51
A dermatology-specific discharge form was developed based on these responses, which was to be
52
completed by the consulting dermatologist and included with the hospital discharge summary. The form
53
was designed to educate consult patients about their dermatologic condition(s) and treatment plan and
54
provide detailed follow-up instructions.
55
The dermatology-specific discharge form was given to 53 consult patients upon discharge in
56
2017. Follow-up appointments were made prior to discharge in reserved slots on the consult resident’s
57
continuity clinic schedule and the appointment information was included on the discharge form. 47
58
consult patients prior to the implementation of the dermatology-specific discharge form were used as
59
historical controls. All patients included were otherwise given the hospital’s standard discharge summary.
60
Follow-up appointment-keeping compliance rates were compared over the 1-year periods before and after
61
the implementation.
3
62
Of the 100 consults included, 57.0% were female with a mean (SD) age of 63.3 (19.7) years. In
63
line with previous studies,2,3 our consultations had a significant impact on the inpatient management of
64
skin conditions, changing the diagnosis and treatment plan in 69% and 83% of cases, respectively (Table
65
1). Multivariate regression analysis showed that patients given the dermatology-specific discharge form
66
were more likely to follow-up compared with consult patients prior to this implementation (60.4% vs.
67
21.2%, RR 2.25; 95% CI 1.18-4.28; p=0.004). Patients with an acute flare of a chronic condition (as
68
compared to an acute new condition) were also more likely to follow-up (RR 2.11; p=0.003), while there
69
was no statistically significant difference in follow-up rates based on age or gender (Table 2).
70
Improved outpatient follow-up compliance rates with use of a dermatology-specific discharge
71
form may be due to improved accuracy and specificity of dermatology information provided to patients
72
upon discharge. One possible contributing factor is that the form is designed to be completed by the
73
consulting dermatologist, as one study found that the accuracy rate of dermatology documentation in
74
hospital discharge summaries completed by nondermatologists was only 54.5%.4
75
The study is limited by its retrospective nature and generalizability given the implementation at a
76
single community based academic medical center. Though patients in the intervention group had reduced
77
all-cause 30-day hospital readmission rates (6.9% vs. 9.2%, p=0.03), it is beyond the scope of this study
78
to correlate this with the higher rates of clinic follow-up. Future studies evaluating use of a dermatology-
79
specific discharge form as a mechanism for reducing readmission rates of inflammatory skin conditions
80
are warranted.
81 82 83 84 85
4
86
References
87
1. Milani-Nejad N, Zhang M, Kaffenberger BH. Association of dermatology consultations with patient
88
care outcomes in hospitalized patients with inflammatory skin diseases. JAMA Dermatol.
89
2017;153(6):523-528.
90
2. Hu L, Haynes H, Ferrazza D, et al. Impact of specialist consultations on inpatient admissions for
91
dermatology-specific and related DRGs. J Gen Intern Med. 2013; 28(11):1477-1482.
92
3. Kroshinsky D, Cotliar J, Hughey LC, et al. Association of dermatology consultation with accuracy of
93
cutaneous disorder diagnoses in hospitalized patients: A multicenter analysis. JAMA Dermatol.
94
2016;152(4):477-480.
95
4. Zhao C, Ang R, George R, et al. The quality of dermatology consultation documentation in discharge
96
summaries: a retrospective analysis. Int J Womens Dermatol. 2016;2(1):23-27.
97 98 99 100 101
Table 1. Impact of Dermatologic Consultations on Diagnoses and Management
Consults (N=100)
Final Diagnosis n (%)
Change from Original Diagnosis
Change in Management
Blistering Disorder
6 (6)
6/6
6/6
Drug Eruption
24 (24)
18/24
20/24
Psoriasis
8 (8)
5/8
7/8
Dermatitis*
21 (21)
15/21
18/21
Cutaneous Malignancy
9 (9)
4/9
9/9
Fungal infection
4 (4)
4/4
4/4
Cellulitis
7 (7)
1/7
2/7
5
Vasculitis
4 (4)
3/4
4/4
Furunculosis
4 (4)
2/4
3/4
Connective Tissue Disease
3 (3)
3/3
2/3
Viral Exanthem
10 (10)
8/10
8/10
69/100 (69%)
83/100 (83%)
102
*Dermatitis including: eczematous dermatitis, contact dermatitis, stasis dermatitis, seborrheic dermatitis
103 104
Table 2. Demographic and Intervention Factors and Follow-up Appointment Success Rates
105 Subgroup
No.a
Completed Follow-up RR (95% CI)
P value
n (%) Sex Female
57
27 (47.3)
1.38 (0.76-2.49)
0.29
Male
43
14 (32.6)
1
Ref
≥65
59
24 (40.6)
1.32 (0.64-2.47)
0.12
<65
41
15 (36.6)
1
Ref
Yes
53
32 (60.4)
2.25 (1.18-4.28) b 0.004
No
47
10 (21.1)
1
Ref
Acute on Chronic
30
18 (60)
2.11 (1.29-3.46)
0.003
Acute
70
22 (31.4)
1
Ref
Age
Dermatology Consult Discharge Form
Condition
106
RR, Risk Ratio; CI, Confidence interval
107
a
108
b
109
Total consults (N=100) Log-binomial regression model after adjustment for age and sex
S0190-9622(20)30141-9
DOI:
https://doi.org/10.1016/j.jaad.2020.01.057
Reference:
YMJD 14190
To appear in:
Journal of the American Academy of Dermatology
Received Date: 16 May 2019 Revised Date:
5 January 2020
Accepted Date: 11 January 2020
Please cite this article as: Miceli A, Krishnamurthy K, Use of a Dermatology-Specific Discharge Form to Improve Outpatient Follow-up after Inpatient Dermatology Consultation, Journal of the American Academy of Dermatology (2020), doi: https://doi.org/10.1016/j.jaad.2020.01.057. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier on behalf of the American Academy of Dermatology, Inc.
1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
Article type: Research Letter Title: Use of a Dermatology-Specific Discharge Form to Improve Outpatient Follow-up after Inpatient Dermatology Consultation Alyssa Miceli, DO1, Karthik Krishnamurthy, DO1 1
Orange Park Medical Center, 906 Park Avenue, Orange Park, FL 32073
Corresponding author: Alyssa Miceli, DO 906 Park Avenue Orange Park, FL 32073 Email: [email protected] Funding sources: American Academy of Dermatology’s Patient Safety and Quality Committee Resident and Fellow Quality Improvement Project Award Conflicts of Interest: None declared. Prior Presentation: Preliminary data presented at the American Academy of Dermatology 2017 Annual Meeting, Orlando, FL. Reprint requests: Alyssa Miceli, DO Manuscript word count: 550 words [excluding references, figures, and tables] Capsule summary word count: N/A References: 4 Figures: 0 Tables: 2 Supplementary Figures: 1 (DOI: 10.17632/hdwswgb23g.2) Attachments: Submission Checklist Keywords: quality improvement; consultations; dermatology; continuity of care; discharge form; outpatient follow-up
2
37
Inpatient dermatology consultations have been shown to be associated with decreased 1-year
38
readmission rates for patients with inflammatory skin conditions.1 We anecdotally identified non-
39
compliance with post-discharge follow-up appointments with consulting dermatologists as a cause of
40
poor outcomes among patients hospitalized for inflammatory skin conditions. To address this area of
41
unmet need, we performed a resident-led quality-improvement project that assessed the effect of
42
implementing a dermatology-specific discharge form on compliance with post-discharge dermatology
43
appointments.
44
Dermatology consult patients who were previously noncompliant with post-discharge
45
appointments were contacted via telephone to identify barriers to follow-up. Some reasons reported
46
included lack of understanding of their inpatient skin diagnoses and the need for long-term outpatient
47
management, discontinuation of the inpatient dermatologic treatment regimen upon discharge, and
48
confusion about how and where to follow-up. Many patients believed that they only needed to follow-up
49
with their primary care physician, suggesting suboptimal communication regarding dermatologic care
50
upon hospital discharge.
51
A dermatology-specific discharge form was developed based on these responses, which was to be
52
completed by the consulting dermatologist and included with the hospital discharge summary. The form
53
was designed to educate consult patients about their dermatologic condition(s) and treatment plan and
54
provide detailed follow-up instructions.
55
The dermatology-specific discharge form was given to 53 consult patients upon discharge in
56
2017. Follow-up appointments were made prior to discharge in reserved slots on the consult resident’s
57
continuity clinic schedule and the appointment information was included on the discharge form. 47
58
consult patients prior to the implementation of the dermatology-specific discharge form were used as
59
historical controls. All patients included were otherwise given the hospital’s standard discharge summary.
60
Follow-up appointment-keeping compliance rates were compared over the 1-year periods before and after
61
the implementation.
3
62
Of the 100 consults included, 57.0% were female with a mean (SD) age of 63.3 (19.7) years. In
63
line with previous studies,2,3 our consultations had a significant impact on the inpatient management of
64
skin conditions, changing the diagnosis and treatment plan in 69% and 83% of cases, respectively (Table
65
1). Multivariate regression analysis showed that patients given the dermatology-specific discharge form
66
were more likely to follow-up compared with consult patients prior to this implementation (60.4% vs.
67
21.2%, RR 2.25; 95% CI 1.18-4.28; p=0.004). Patients with an acute flare of a chronic condition (as
68
compared to an acute new condition) were also more likely to follow-up (RR 2.11; p=0.003), while there
69
was no statistically significant difference in follow-up rates based on age or gender (Table 2).
70
Improved outpatient follow-up compliance rates with use of a dermatology-specific discharge
71
form may be due to improved accuracy and specificity of dermatology information provided to patients
72
upon discharge. One possible contributing factor is that the form is designed to be completed by the
73
consulting dermatologist, as one study found that the accuracy rate of dermatology documentation in
74
hospital discharge summaries completed by nondermatologists was only 54.5%.4
75
The study is limited by its retrospective nature and generalizability given the implementation at a
76
single community based academic medical center. Though patients in the intervention group had reduced
77
all-cause 30-day hospital readmission rates (6.9% vs. 9.2%, p=0.03), it is beyond the scope of this study
78
to correlate this with the higher rates of clinic follow-up. Future studies evaluating use of a dermatology-
79
specific discharge form as a mechanism for reducing readmission rates of inflammatory skin conditions
80
are warranted.
81 82 83 84 85
4
86
References
87
1. Milani-Nejad N, Zhang M, Kaffenberger BH. Association of dermatology consultations with patient
88
care outcomes in hospitalized patients with inflammatory skin diseases. JAMA Dermatol.
89
2017;153(6):523-528.
90
2. Hu L, Haynes H, Ferrazza D, et al. Impact of specialist consultations on inpatient admissions for
91
dermatology-specific and related DRGs. J Gen Intern Med. 2013; 28(11):1477-1482.
92
3. Kroshinsky D, Cotliar J, Hughey LC, et al. Association of dermatology consultation with accuracy of
93
cutaneous disorder diagnoses in hospitalized patients: A multicenter analysis. JAMA Dermatol.
94
2016;152(4):477-480.
95
4. Zhao C, Ang R, George R, et al. The quality of dermatology consultation documentation in discharge
96
summaries: a retrospective analysis. Int J Womens Dermatol. 2016;2(1):23-27.
97 98 99 100 101
Table 1. Impact of Dermatologic Consultations on Diagnoses and Management
Consults (N=100)
Final Diagnosis n (%)
Change from Original Diagnosis
Change in Management
Blistering Disorder
6 (6)
6/6
6/6
Drug Eruption
24 (24)
18/24
20/24
Psoriasis
8 (8)
5/8
7/8
Dermatitis*
21 (21)
15/21
18/21
Cutaneous Malignancy
9 (9)
4/9
9/9
Fungal infection
4 (4)
4/4
4/4
Cellulitis
7 (7)
1/7
2/7
5
Vasculitis
4 (4)
3/4
4/4
Furunculosis
4 (4)
2/4
3/4
Connective Tissue Disease
3 (3)
3/3
2/3
Viral Exanthem
10 (10)
8/10
8/10
69/100 (69%)
83/100 (83%)
102
*Dermatitis including: eczematous dermatitis, contact dermatitis, stasis dermatitis, seborrheic dermatitis
103 104
Table 2. Demographic and Intervention Factors and Follow-up Appointment Success Rates
105 Subgroup
No.a
Completed Follow-up RR (95% CI)
P value
n (%) Sex Female
57
27 (47.3)
1.38 (0.76-2.49)
0.29
Male
43
14 (32.6)
1
Ref
≥65
59
24 (40.6)
1.32 (0.64-2.47)
0.12
<65
41
15 (36.6)
1
Ref
Yes
53
32 (60.4)
2.25 (1.18-4.28) b 0.004
No
47
10 (21.1)
1
Ref
Acute on Chronic
30
18 (60)
2.11 (1.29-3.46)
0.003
Acute
70
22 (31.4)
1
Ref
Age
Dermatology Consult Discharge Form
Condition
106
RR, Risk Ratio; CI, Confidence interval
107
a
108
b
109
Total consults (N=100) Log-binomial regression model after adjustment for age and sex