patients admitted to general medical wards are increasingly being cared for by hospital - based physicians , or hospitalists.13 these clinicians specialize in general medical care of hospitalized patients and seldom see outpatients as primary care providers ( pcps ) . upon discharge of their patients , hospital - based physicians usually transfer care to the patient s usual pcp.46 there are many benefits to the hospitalist model.3,4 however , a major concern of the hospitalist movement relates to the separation of hospital and ambulatory care.7 this may result in patient care discontinuities because of a lack of pcp involvement in their patient s hospital care . poor care continuity may become most evident when a patient is discharged from hospital because pcps often are unaware that their patient was hospitalized and frequently do not receive discharge summaries.8,9 in addition , poor information transfer can result in potentially preventable adverse events.10 communication between the hospital physician and pcp can begin when the patient is admitted , occur throughout the hospitalization , and aid in management after hospital discharge . therefore , in the absence of a discharge summary , a pcp can still be involved in important information transfer through other , and often preferred , communication methods.11 we report the results of a study linking a survey of hospital physician communication with pcps to important 30-day patient outcomes . our objective was to determine whether pcp knowledge of their patient s hospital admission , receipt of a discharge summary , and direct communication with the inpatient medical team are associated with 30-day composite patient outcomes of death , hospital readmission , or emergency department ( ed ) visit . the study was part of a large , multi - center trial evaluating the effects of hospitalists on costs and outcomes in hospitalized general medicine patients at six academic medical centers throughout the us : brigham and women s hospital ( bwh ) in boston , massachusetts ; university of chicago medical center ( uc ) in chicago , illinois ; university of california san francisco medical center ( ucsf ) in san francisco , california ; university of iowa hospitals and clinics ( ui ) in iowa city , iowa ; university of new mexico medical center ( unm ) in albuquerque , new mexico ; and university of wisconsin hospital and clinics ( uw ) in madison , wisconsin.12 approval for our study was obtained from the institutional review boards at all six participating sites . our study population included consecutive patients providing informed consent and physician contact information from the 31,891 patients admitted from july 2001-june 2003 to general medicine services at the six hospitals . patients were quasi - randomized to medical teams based on a day of the week - based call schedule or by the last digit of the patient s medical record number , depending on the site . if patients were unable to provide consent due to cognitive impairment , consent was sought through designated proxy.13 patients were excluded from this part of the study if they were transferred to another service before discharge or died during hospitalization . only patients enrolled in the study who were discharged alive from hospital and completed a follow - up phone call were included in the analyses . all patients , regardless of whether they were assigned to hospitalist or non - hospitalist care , were eligible for the study . hospitalist physicians were defined by the individual institutions . in general , this corresponded to at least 23  months per year of ward clinical service with the majority performing 3 to 6  months , depending on the individual site . the non - hospitalist physicians were generally internal medicine subspecialists and outpatient - based general internists . patients or their proxies were telephoned 30 days after hospital discharge and asked about readmission to hospital or ed visits after discharge . re - admission or ed visit could be to the same or a different hospital . patients were also linked to the national death index ( ndi ) to assess for 30-day mortality . the primary composite outcome of interest was death , hospital readmission , or ed presentation within 30  days from hospital discharge . patients identified their pcp during an inpatient interview , and then a random sample of these patients primary care providers ( pcps ) was surveyed via a faxed questionnaire 2 weeks after patient discharge . depending on the site , the pcp for one in two ( unm ) , one in five ( uc , uw ) , or one in ten ( bwh , ucsf , ui ) study patients discharged from the hospital was surveyed . this differential sampling was done because of limited resources at some centers and because of the prior knowledge that fewer patients at unm had pcps . the pcp survey was developed from reviewing relevant themes from the literature after an extensive literature search was unable to identify any suitable pre - existing instruments ( appendix ) . it was pilot tested on primary care providers at the university of chicago prior to the study . the survey examined attitudes concerning the care and quality of communication provided by the inpatient physician , as well as whether or not the pcp had been aware of the patient s admission . the survey included 12 questions and asked about aspects of the communication , including the specific member of the team ( e.g. , nurse , medical student , attending physician ) , the timing of the communication ( e.g. , at admission , during the hospitalization , at discharge ) , and the type of method ( e.g. , phone , fax , or e - mail ) . the questions regarding the quality of communication were rated on a five - point scale ( excellent , very good , good , fair , and poor ) . we used hierarchical , multi - variable , logistic regression techniques to model the association between communication with the patient s pcp and a 30-day composite outcome of ed visit , hospital readmission , or death adjusting for patient age , race , sex , charlson comorbidity score , and study site.14 we also accounted for whether the patient s attending physician was defined by their institution as a hospitalist . odds ratios were calculated compared to the reference group of patients with pcps not aware of their hospitalization . power calculations demonstrated that we had 79% power to detect a 9% difference for our primary question . the study was part of a large , multi - center trial evaluating the effects of hospitalists on costs and outcomes in hospitalized general medicine patients at six academic medical centers throughout the us : brigham and women s hospital ( bwh ) in boston , massachusetts ; university of chicago medical center ( uc ) in chicago , illinois ; university of california san francisco medical center ( ucsf ) in san francisco , california ; university of iowa hospitals and clinics ( ui ) in iowa city , iowa ; university of new mexico medical center ( unm ) in albuquerque , new mexico ; and university of wisconsin hospital and clinics ( uw ) in madison , wisconsin.12 approval for our study was obtained from the institutional review boards at all six participating sites . our study population included consecutive patients providing informed consent and physician contact information from the 31,891 patients admitted from july 2001-june 2003 to general medicine services at the six hospitals . patients were quasi - randomized to medical teams based on a day of the week - based call schedule or by the last digit of the patient s medical record number , depending on the site . if patients were unable to provide consent due to cognitive impairment , consent was sought through designated proxy.13 patients were excluded from this part of the study if they were transferred to another service before discharge or died during hospitalization . patients previously enrolled in the study were eligible for subsequent inclusion . only patients enrolled in the study who were discharged alive from hospital and completed a follow - up phone call all patients , regardless of whether they were assigned to hospitalist or non - hospitalist care , were eligible for the study . hospitalist physicians were defined by the individual institutions . in general , this corresponded to at least 23  months per year of ward clinical service with the majority performing 3 to 6  months , depending on the individual site . the non - hospitalist physicians were generally internal medicine subspecialists and outpatient - based general internists . patients or their proxies were telephoned 30 days after hospital discharge and asked about readmission to hospital or ed visits after discharge . re - admission or ed visit could be to the same or a different hospital . patients were also linked to the national death index ( ndi ) to assess for 30-day mortality . the primary composite outcome of interest was death , hospital readmission , or ed presentation within 30  days from hospital discharge . patients identified their pcp during an inpatient interview , and then a random sample of these patients primary care providers ( pcps ) was surveyed via a faxed questionnaire 2 weeks after patient discharge . depending on the site , the pcp for one in two ( unm ) , one in five ( uc , uw ) , or one in ten ( bwh , ucsf , ui ) study patients discharged from the hospital was surveyed . this differential sampling was done because of limited resources at some centers and because of the prior knowledge that fewer patients at unm had pcps . the pcp survey was developed from reviewing relevant themes from the literature after an extensive literature search was unable to identify any suitable pre - existing instruments ( appendix ) . it was pilot tested on primary care providers at the university of chicago prior to the study . the survey examined attitudes concerning the care and quality of communication provided by the inpatient physician , as well as whether or not the pcp had been aware of the patient s admission . the survey included 12 questions and asked about aspects of the communication , including the specific member of the team ( e.g. , nurse , medical student , attending physician ) , the timing of the communication ( e.g. , at admission , during the hospitalization , at discharge ) , and the type of method ( e.g. , phone , fax , or e - mail ) . the questions regarding the quality of communication were rated on a five - point scale ( excellent , very good , good , fair , and poor ) . we used hierarchical , multi - variable , logistic regression techniques to model the association between communication with the patient s pcp and a 30-day composite outcome of ed visit , hospital readmission , or death adjusting for patient age , race , sex , charlson comorbidity score , and study site.14 we also accounted for whether the patient s attending physician was defined by their institution as a hospitalist . odds ratios were calculated compared to the reference group of patients with pcps not aware of their hospitalization . power calculations demonstrated that we had 79% power to detect a 9% difference for our primary question . during the study period , 2,526 patients consented to have their pcp contacted , and 2,336 of these had valid pcp contact information . from these patients , we then excluded 423 patients who were lost to follow - up after discharge , leaving 1,078 patients for analysis . the patient s inpatient attending physician was a hospitalist in 34% ( 371/1,078 ) of patients . patients of pcps who responded to the pcp survey had a mean age of 59  years , were mostly female , had a mean administrative - data - derived charlson score of 1.1 ( sd 1.5 ) , and were mostly white . patients of pcp respondents differed little from pcp non - respondents except that they more commonly experienced the composite outcome and were less likely to be african - american . table  1comparison of patient demographics and outcomes for non - responder and responder primary care providers  pcp respondentspcp non - respondentsp - value*n  =  1,078n  =  605demographics  mean age ( sd)60 ( 19)58 ( 18)0.08  female ( % ) 658 ( 61)363 ( 60)0.68  african american ( % ) 280 ( 26)187 ( 31)0.04mean charlson comorbidity score ( sd)1.1 ( 1.5)1.1 ( 1.4)0.64outcomes  ed visit within 30 days ( % ) 69 ( 6.4)34 ( 5.6)0.52  readmission within 30 days ( % ) 116 ( 11)57 ( 9.4)0.38  death within 30 days ( % ) 82 ( 7.6)35 ( 5.8)0.16composite outcome measure ( % ) 233 ( 22)107 ( 18)0.05*not corrected for multiple comparisonspcp = primary care providersd = standard deviationed = emergency departmentcomposite outcome = hospital readmission or emergency department visit or death within 30  days of hospital discharge comparison of patient demographics and outcomes for non - responder and responder primary care providers * not corrected for multiple comparisons pcp = primary care provider sd = standard deviation ed = emergency department composite outcome = hospital readmission or emergency department visit or death within 30  days of hospital discharge overall , the pcps for 834 patients ( 77% ) were aware that their patient was admitted to the hospital . there was no statistically significant difference in the pcp s knowledge of admission between hospitalist and non - hospitalist attendings ( 81% vs. 78% ; p  =  0.2 ) . of those pcps aware of the admission , there was direct communication with the general medicine service for 194 ( 23% ) patients , and 347 ( 42% ) pcps reported seeing a discharge summary by 2 weeks after patient discharge . within 30  days of discharge , 82 ( 7.6% ) patients died , 116 ( 10.8% ) patients were readmitted to hospital , and 69 ( 6.4% ) patients visited an ed . the composite outcome occurred in a total of 233 ( 22% ) patients : 49 ( 20% ) when the pcp was not aware of the hospitalization and 184 ( 22% ) when the pcp was aware of the hospitalization . ( table  2 ) 
 table  2thirty - day outcomes and pcp communicationsurvey question30-day outcomes  readmission ( % ) ed visit ( % ) death ( % ) composite outcome ( % ) pcp not aware of hospitalization ( n  =  244)21 ( 8.6)19 ( 7.7)18 ( 7.3)49 ( 20)pcp aware of hospitalization ( n  =  834)95 ( 11.4)51 ( 6.1)62 ( 7.4)184 ( 22)among those patients whose pcps were aware of hospital admission : communicated with inpatient teamno ( n  =  640)79 ( 12.4)56 ( 8.8)53 ( 8.3)166 ( 26)yes ( n  =  194)22 ( 11.2)11 ( 5.5)14 ( 7.4)41 ( 21)seen discharge summaryno ( n  =  487)59 ( 12.1)30 ( 6.1)32 ( 6.6)112 ( 23)yes ( n  =  347)36 ( 10.4)24 ( 6.9)28 ( 8.1)73 ( 21)ed = emergency departmentcomposite outcome = hospital readmission or emergency department visit or death within 30  days of hospital dischargepcp = primary care provider thirty - day outcomes and pcp communication ed = emergency department composite outcome = hospital readmission or emergency department visit or death within 30  days of hospital discharge pcp = primary care provider multi - variable analysis found that pcp awareness of their patient s index admission to hospital was not associated with risk of the composite outcome ( adjusted odds ratio 1.08 , 95% confidence interval 0.73 to 1.59 ) . similarly , there were no significant differences in adjusted 30-day composite outcomes if the pcp communicated directly with the hospital team ( adjusted or 0.87 , 95% ci 0.56 to 1.34 ) or if the pcp saw a discharge summary ( adjusted or 0.84 , 95% ci 0.57 to 1.22 ) . whether the in - hospital attending physician was a hospitalist had no effect on the composite outcome ( adjusted or 0.99 , 95% 0.71 to 1.4 ) . during the study period , 2,526 patients consented to have their pcp contacted , and 2,336 of these had valid pcp contact information . from these patients , we then excluded 423 patients who were lost to follow - up after discharge , leaving 1,078 patients for analysis . the patient s inpatient attending physician was a hospitalist in 34% ( 371/1,078 ) of patients . patients of pcps who responded to the pcp survey had a mean age of 59  years , were mostly female , had a mean administrative - data - derived charlson score of 1.1 ( sd 1.5 ) , and were mostly white . patients of pcp respondents differed little from pcp non - respondents except that they more commonly experienced the composite outcome and were less likely to be african - american . table  1comparison of patient demographics and outcomes for non - responder and responder primary care providers  pcp respondentspcp non - respondentsp - value*n  =  1,078n  =  605demographics  mean age ( sd)60 ( 19)58 ( 18)0.08  female ( % ) 658 ( 61)363 ( 60)0.68  african american ( % ) 280 ( 26)187 ( 31)0.04mean charlson comorbidity score ( sd)1.1 ( 1.5)1.1 ( 1.4)0.64outcomes  ed visit within 30 days ( % ) 69 ( 6.4)34 ( 5.6)0.52  readmission within 30 days ( % ) 116 ( 11)57 ( 9.4)0.38  death within 30 days ( % ) 82 ( 7.6)35 ( 5.8)0.16composite outcome measure ( % ) 233 ( 22)107 ( 18)0.05*not corrected for multiple comparisonspcp = primary care providersd = standard deviationed = emergency departmentcomposite outcome = hospital readmission or emergency department visit or death within 30  days of hospital discharge comparison of patient demographics and outcomes for non - responder and responder primary care providers * not corrected for multiple comparisons pcp = primary care provider sd = standard deviation ed = emergency department composite outcome = hospital readmission or emergency department visit or death within 30  days of hospital discharge overall , the pcps for 834 patients ( 77% ) were aware that their patient was admitted to the hospital . there was no statistically significant difference in the pcp s knowledge of admission between hospitalist and non - hospitalist attendings ( 81% vs. 78% ; p  =  0.2 ) . of those pcps aware of the admission , there was direct communication with the general medicine service for 194 ( 23% ) patients , and 347 ( 42% ) pcps reported seeing a discharge summary by 2 weeks after patient discharge . within 30  days of discharge , 82 ( 7.6% ) patients died , 116 ( 10.8% ) patients were readmitted to hospital , and 69 ( 6.4% ) patients visited an ed . the composite outcome occurred in a total of 233 ( 22% ) patients : 49 ( 20% ) when the pcp was not aware of the hospitalization and 184 ( 22% ) when the pcp was aware of the hospitalization . ( table  2 ) 
 table  2thirty - day outcomes and pcp communicationsurvey question30-day outcomes  readmission ( % ) ed visit ( % ) death ( % ) composite outcome ( % ) pcp not aware of hospitalization ( n  =  244)21 ( 8.6)19 ( 7.7)18 ( 7.3)49 ( 20)pcp aware of hospitalization ( n  =  834)95 ( 11.4)51 ( 6.1)62 ( 7.4)184 ( 22)among those patients whose pcps were aware of hospital admission : communicated with inpatient teamno ( n  =  640)79 ( 12.4)56 ( 8.8)53 ( 8.3)166 ( 26)yes ( n  =  194)22 ( 11.2)11 ( 5.5)14 ( 7.4)41 ( 21)seen discharge summaryno ( n  =  487)59 ( 12.1)30 ( 6.1)32 ( 6.6)112 ( 23)yes ( n  =  347)36 ( 10.4)24 ( 6.9)28 ( 8.1)73 ( 21)ed = emergency departmentcomposite outcome = hospital readmission or emergency department visit or death within 30  days of hospital dischargepcp = primary care provider thirty - day outcomes and pcp communication ed = emergency department composite outcome = hospital readmission or emergency department visit or death within 30  days of hospital discharge pcp = primary care provider multi - variable analysis found that pcp awareness of their patient s index admission to hospital was not associated with risk of the composite outcome ( adjusted odds ratio 1.08 , 95% confidence interval 0.73 to 1.59 ) . similarly , there were no significant differences in adjusted 30-day composite outcomes if the pcp communicated directly with the hospital team ( adjusted or 0.87 , 95% ci 0.56 to 1.34 ) or if the pcp saw a discharge summary ( adjusted or 0.84 , 95% ci 0.57 to 1.22 ) . whether the in - hospital attending physician was a hospitalist had no effect on the composite outcome ( adjusted or 0.99 , 95% 0.71 to 1.4 ) . in a multicenter study of hospitalists and non - hospitalists in six us academic medical centers , few primary care providers ( pcps ) had direct communication with the inpatient medical team during their patients hospitalizations , more than half reported not receiving a discharge summary within 2 weeks , and almost one quarter did not have any knowledge that their patients had been admitted at all . however , these lapses in communication were not associated with adjusted 30-day risk for death , hospital readmission , or emergency department visits . much has been discussed about the importance of discharge communication for hospitalized patients , but little work has evaluated  hard  outcomes.9 most previous studies of inter - physician communication have focused on process measures or surrogate markers , such as decreased laboratory test repetition , reduced emergency department waits , improved glycosylated hemoglobin levels , and higher cancer screening rates.1518 however , not all work has demonstrated improved patient care.19,20 perhaps the largest study that evaluated communication between hospital - based and ambulatory - care physicians with respect to patient outcomes assessed almost 900 patients and found that discharge summaries were available to treating physicians in less than 25% of follow - up visits.21 however , adjusted analyses of 90-day risk of hospital readmission related to discharge summary availability were not significant ( odds ratio 0.74 ; 95% ci 0.05 to 1.10 ) . this study involved only a single center and only measured hospital readmission at 90 days as compared to a composite outcome of 30-day death , hospital readmission , or ed visit that is now the standard for many studies of quality . although our observed rate of pcp - hospital - based physician communication showed that almost one - quarter of pcps were unaware that their patient was hospitalized , it is far lower than the average described in a recent systematic review.9 previous studies have documented that formal direct communication between hospital and primary care physicians within 2 weeks occurs less than two - thirds of the time ( range 2980% ) depending on the study and communication type.9 our findings may be due to the expectation that residents contact pcps at many of the sites . further , rates observed in earlier work could be due to publication bias underscoring poor performance and may have preceded the recent and widespread adoption of the hospitalist movement , which emphasizes timely communication.1,2,4,5,11 the lack of a significant relationship between these aspects of communication and patient outcomes after discharge may be explained by several factors . the effects of direct communication and receipt of a discharge summary were associated with non - significant reductions in the composite outcome . that knowledge of the admission did not show even a non - significant trend towards improved outcomes may have been due to chance or to the fact that simple knowledge of admission may not be sufficient to improve outcomes . also , pcps may have other means of discovering that their patient was admitted to hospital and may take appropriate steps for follow - up.11 second , the presence of any communication is not the same as receipt of high - quality communication , and only the latter may be capable of improving outcomes . third , there are many other factors that can lead to ed visits , hospital readmission , or death besides presence and quality of communication , thus limiting our ability to find an effect . fourth , patients may have misreported ed visits and hospital readmissions , leading to measurement bias towards the null . fifth , there may be confounding by indication : inpatient physicians may be more likely to communicate with pcps regarding patients who are particularly at high risk for adverse outcomes after discharge . we did not assess for this aspect  particularly because many of our patients were younger and had fewer comorbidities . finally , there may be other patient confounders of the outcome that could not be adjusted for in our analyses . interestingly , we observed little difference in pcp responses or adjusted patient outcomes between patients cared for by hospitalists compared to other attending physicians first , hospitalist physicians may not have that large of an effect on the patient outcomes measured in this study even though there may be other benefits . second , the major role that residents have in patient care in academic centers may mitigate some of the effect of the attending physician . also , many of the hospitalists in our study were relatively inexperienced , and it may take a while to hone communication skills and develop relationships with community pcps.12 finally , there may be systemic barriers to communication ( e.g. , incorrect pcp contact information ) that apply equally to all attending physicians . first , our study was not designed to determine how improved communication and information transfer might avoid adverse outcomes . second , no sites involved in the study employed standardized templates for discharge summaries during the study , even though it is a recommended practice.9,22 third , the surveys measured pcp knowledge of patient hospitalization at 2 weeks . this should have allowed enough time for any informal communication or the delivery of formal discharge summaries . however , pcps may still have received information after the survey was completed but prior to their patient s follow - up visit . although many community hospitals may have closer relationships with pcps , an increasing number of community hospitals also rely on hospitalist models of care , and the findings may therefore apply.1,2,4 finally , our composite outcome of 30-day death , hospital or ed admission is not the only relevant metric . we did not present any information on other important patient outcomes like adverse drug events , missed follow - up , quality of life , and patient satisfaction.10,23,24 our findings are strengthened by several aspects of this study . further , we included data on the availability of the discharge summary as well as other communication strategies that may be preferred by pcps , such as telephone or e - mail.11 our use of a composite outcome allowed us to increase the statistical power of our study while still incorporating relevant quality of care measures . finally , we had a high response rate of 70% , limiting the potential impact of respondent bias . patients are being discharged from hospitals quicker and sicker than in previous years.10,2527 consequently , adequate follow - up and care continuity increases in importance . though our results provide no direct link between physician communication and important patient outcomes , they demonstrate that communication between hospital physicians and pcps can be substantially improved .
abstractbackgroundpatients admitted to general medicine inpatient services are increasingly cared for by hospital - based physicians rather than their primary care providers ( pcps ) . 
 this separation of hospital and ambulatory care may result in important care discontinuities after discharge . 
 we sought to determine whether communication between hospital - based physicians and pcps influences patient outcomes.methodswe approached consecutive patients admitted to general medicine services at six us academic centers from july 2001 to june 2003 . 
 a random sample of the pcps for consented patients was contacted 2 weeks after patient discharge and surveyed about communication with the hospital medical team . 
 responses were linked with the 30-day composite patient outcomes of mortality , hospital readmission , and emergency department ( ed ) visits obtained through follow - up telephone survey and national death index search . 
 we used hierarchical multi - variable logistic regression to model whether communication with the patient s pcp was associated with the 30-day composite outcome.resultsa total of 1,772 pcps for 2,336 patients were surveyed with 908 pcps responses and complete patient follow - up available for 1,078 patients . 
 the pcps for 834 patients ( 77% ) were aware that their patient had been admitted to the hospital . 
 of these , direct communication between pcps and inpatient physicians took place for 194 patients ( 23% ) , and a discharge summary was available within 2 weeks of discharge for 347 patients ( 42% ) . within 30  days of discharge , 233 ( 22% ) patients died , were readmitted to the hospital , or visited an ed . in adjusted analyses , no relationship was seen between the composite outcome and direct physician communication ( adjusted odds ratio 0.87 , 95% confidence interval 0.56  1.34 ) , the presence of a discharge summary ( 0.84 , 95% ci 0.571.22 ) , or pcp awareness of the index hospitalization ( 1.08 , 95% ci 0.731.59).conclusionanalysis of communication between pcps and inpatient medical teams revealed much room for improvement . although communication during handoffs of care is important , we were not able to find a relationship between several aspects of communication and associated adverse clinical outcomes in this multi - center patient sample .