Public Health
(1991), 105, 243~47
© The Societyof Public Health, 1991
Hospital Discharge Medication: is Seven Days Supply Sufficient? C. Kenny Registrar in Public Health Medicine, Southern Derbyshire Health Authority, Boden House, Derby, DE1 2PH
The impact of a change in a District Health Authority's hospital medication discharge policy, from 14 to 7 days supply, was evaluated. This coincided with a revised initial discharge letter (prescription and clinical details combined). There was no significant difference between a 14 and 7 day supply with regard to whether GP's received an initial discharge letter, the number of days the letter took to arrive at the GP's surgery, the necessity for further treatment, or problems encountered in the continuity of a patient's treatment. However there was a significant improvement (P0.05.
Table lII
Reasons given by GPs why patients had problems with continuity of medication
Reason given
Part I (14 day)
Part II (7 day)
3 2
6 0
Home visit required Delay in patient contact Inadequate information on discharge letter No discharge letter received Patient unable to get to surgery Dependence on third party Chemist closed Remote location of patient
1 1 l
0 0 1
0 0 0
2 1 1
Total
8
11
only two of the Part II study patients did. F r o m the G P ' s point o f view, 12% o f patients in Part I (8/89) and 1 5 % o f patients in Part II (11/77) encountered problems; reasons given are shown in Table III. Discussion
While the change in discharge medication policy was being debated a n u m b e r of points were made by the local medical committee who suggested ways in which the new policy m a y be detrimental to patient care. In the light of the financial savings to the Authority consequent u p o n the new policy these points need to be carefully considered:
1. "The initial discharge letter will take too long to arrive at the GP's surgery.' This statement is not supported by this study: for those patients who said they received a letter, 96% (Part I) and 94% (Part II) got it to their G P within seven days. This is similar to other recent studies) "6It was not possible to assess this time delay from the G P s ' point o f view, as less than half of the G P s who said they received a letter could say when it arrived. Moreover, as all letters were hand-delivered no G P was put in the position o f seeing a patient after discharge prior to the discharge letter arriving by post. In a recent study this situation arose for over half o f discharged patients. 2
246
C. Kenny
2. 'The quality of information on the discharge letter is often so poor that it is difficult to write a further prescription.' A number of studies have investigated the quality of hospital discharge letters ~'2'7'8although none specifically reports whether the quality affected a GP's ability to write a further prescription. The present study has shown a significant increase (70% versus 92%, P < 0.01) in the proportion of GPs who said the discharge letter information was adequate to write a further prescription. This is certainly due to the restyled discharge letter, combining clinical and prescription details, which started at the same time as the new medication supply policy. 3. 'Seven days supply is insufficient for some people to obtain a further prescription and may lead to a discontinuity o f medication." This was a key point to be answered by this study. Only two patients said they had such difficulty (both during Part II) and the reasons given 'hospital only' medication required and inability to get to the surgery - were not sufficient to justify a reversal to the 14 day policy. The reasons GPs gave (Table III) show that the change in policy had a very small effect indeed. The problem o f seven days supply being insufficient over Bank Holiday weekends was taken into account by giving an extra days supply for each Bank Holiday that occurred during the seven day period. 4. 'The new policy will increase the workload of GPs." There is no evidence for this. The new policy did not increase the number of patients being admitted or discharged; it merely affected the timing of a discharged patient's contact with their GP. 5. "Elderly patients would suffer more than younger patients.' This is not supported by this study. No differences were detected in responses from the two age groups (16-64 and 65 and over). 6. 'The new policy will increase the overall cost o f drugs to the Health Service.' This is true and such cost transfers will continue while District Health Authority budgets are cash limited and General Practice budgets are not. The differences in cost between drugs supplied to retail pharmacists and those supplied on contract to District Health Authorities can be o f the order of two or three times, but will often depend on whether generic or brand names are dispensed. However it is probable that with the introduction o f indicative drug budgets within General Practice in 1991/92 such cost transfers will not produce any significant financial savings as the cost o f all drugs, whether prescribed in hospital or in General Practice, will be met from the Regional Health Authority's cash limit. For a truly valid comparison of the results of Parts I and II, the methodology o f data collection in both parts needs to be identical, but in this study the sampling frame for Part I consisted of patients over a 14 day period, whereas Part II covered patients over a 31 day period. However the method of random selection o f patients from each sampling frame ensured that both samples selected were representative of the patients under investigation and also ensured that no selection bias was introduced. In addition, because of the different timings of the two sampling frames, the maximum time between discharge and receiving a questionnaire for the two parts was slightly different (four weeks versus six weeks). This may have introduced a differential recall bias but this is likely to have been very small and is very unlikely to affect the overall results and conclusions. Although the original reason for suggesting a change in policy was financial (about £40,000 savings per year) it was noted that some Health Authorities already operated
Hospital Discharge Medication
247
successful seven day policies. For example in the Trent Region, District policies ranged from 14 days supply to no supply at all. It is difficult to understand how this latter policy could operate successfully without extreme hardship to patients. In these days o f cost improvements and financial hardships, District Health Authorities need to look closely at the effect any change in policy has on patient care. This study has shown that as long as the discharge letter has prescription details on it and is delivered by hand, seven days supply o f medication has no detrimental effect on patient care. It is likely that the speed o f delivery and quality of information on discharge letters are more important factors than the n u m b e r o f days medication supplied, although seven days is probably optimal.
Acknowledgements I would like to thank Dr L. M. Davies, Dr S. M. Whitehead, Dr J. Grenville, Mr M. Cullen and Professor R. Madeley for their help in the preparation of this paper, and Mrs J. Bridge for typing the manuscript.
References 1. Tulloch, A. J., Fowler, G. H., McMullan, J. J. & Spence, J. M. (1975). Hospital discharge reports: content and design. British Medical Journal, 4, 443~146. 2. Mageean, R.J. (1986). Study of 'discharge communications' from hospital. British Medical Journal, 293, 1283-1284. 3. Sandler, D.A. & Mitchell, J. R. A. (1987). Interim discharge summaries: How are they best delivered to general practitioners? British Medical Journal, 295, 1523-1525. 4. Dover, S. B. & Low Beer, T. S. (1984). The initial hospital discharge note: send out with the patient or post? Health Trends, 16, 48. 5. Kendrick, A. R. & Hindmarsh, D. J. (1989). Which type of hospital discharge report reaches General Practitioners most quickly? British Medical Journal, 298, 362-363 6. Penney, T. M. (1988) Delayed communication between hospitals and general practitioners: where does the problem lie? British Medical Journal, 297, 28-29. 7. Long, A. & Atkins, J. B. (1974). Communications between General Practitioners and Consultants. British Medical Journal, 4, 456~59. 8. Harding, J. (1987). Study of discharge communications from hospital doctors to an inner London General Practice. Journal of the Royal College of General Practitioners, 37, 494-495.
(1991), 105, 243~47
© The Societyof Public Health, 1991
Hospital Discharge Medication: is Seven Days Supply Sufficient? C. Kenny Registrar in Public Health Medicine, Southern Derbyshire Health Authority, Boden House, Derby, DE1 2PH
The impact of a change in a District Health Authority's hospital medication discharge policy, from 14 to 7 days supply, was evaluated. This coincided with a revised initial discharge letter (prescription and clinical details combined). There was no significant difference between a 14 and 7 day supply with regard to whether GP's received an initial discharge letter, the number of days the letter took to arrive at the GP's surgery, the necessity for further treatment, or problems encountered in the continuity of a patient's treatment. However there was a significant improvement (P0.05.
Table lII
Reasons given by GPs why patients had problems with continuity of medication
Reason given
Part I (14 day)
Part II (7 day)
3 2
6 0
Home visit required Delay in patient contact Inadequate information on discharge letter No discharge letter received Patient unable to get to surgery Dependence on third party Chemist closed Remote location of patient
1 1 l
0 0 1
0 0 0
2 1 1
Total
8
11
only two of the Part II study patients did. F r o m the G P ' s point o f view, 12% o f patients in Part I (8/89) and 1 5 % o f patients in Part II (11/77) encountered problems; reasons given are shown in Table III. Discussion
While the change in discharge medication policy was being debated a n u m b e r of points were made by the local medical committee who suggested ways in which the new policy m a y be detrimental to patient care. In the light of the financial savings to the Authority consequent u p o n the new policy these points need to be carefully considered:
1. "The initial discharge letter will take too long to arrive at the GP's surgery.' This statement is not supported by this study: for those patients who said they received a letter, 96% (Part I) and 94% (Part II) got it to their G P within seven days. This is similar to other recent studies) "6It was not possible to assess this time delay from the G P s ' point o f view, as less than half of the G P s who said they received a letter could say when it arrived. Moreover, as all letters were hand-delivered no G P was put in the position o f seeing a patient after discharge prior to the discharge letter arriving by post. In a recent study this situation arose for over half o f discharged patients. 2
246
C. Kenny
2. 'The quality of information on the discharge letter is often so poor that it is difficult to write a further prescription.' A number of studies have investigated the quality of hospital discharge letters ~'2'7'8although none specifically reports whether the quality affected a GP's ability to write a further prescription. The present study has shown a significant increase (70% versus 92%, P < 0.01) in the proportion of GPs who said the discharge letter information was adequate to write a further prescription. This is certainly due to the restyled discharge letter, combining clinical and prescription details, which started at the same time as the new medication supply policy. 3. 'Seven days supply is insufficient for some people to obtain a further prescription and may lead to a discontinuity o f medication." This was a key point to be answered by this study. Only two patients said they had such difficulty (both during Part II) and the reasons given 'hospital only' medication required and inability to get to the surgery - were not sufficient to justify a reversal to the 14 day policy. The reasons GPs gave (Table III) show that the change in policy had a very small effect indeed. The problem o f seven days supply being insufficient over Bank Holiday weekends was taken into account by giving an extra days supply for each Bank Holiday that occurred during the seven day period. 4. 'The new policy will increase the workload of GPs." There is no evidence for this. The new policy did not increase the number of patients being admitted or discharged; it merely affected the timing of a discharged patient's contact with their GP. 5. "Elderly patients would suffer more than younger patients.' This is not supported by this study. No differences were detected in responses from the two age groups (16-64 and 65 and over). 6. 'The new policy will increase the overall cost o f drugs to the Health Service.' This is true and such cost transfers will continue while District Health Authority budgets are cash limited and General Practice budgets are not. The differences in cost between drugs supplied to retail pharmacists and those supplied on contract to District Health Authorities can be o f the order of two or three times, but will often depend on whether generic or brand names are dispensed. However it is probable that with the introduction o f indicative drug budgets within General Practice in 1991/92 such cost transfers will not produce any significant financial savings as the cost o f all drugs, whether prescribed in hospital or in General Practice, will be met from the Regional Health Authority's cash limit. For a truly valid comparison of the results of Parts I and II, the methodology o f data collection in both parts needs to be identical, but in this study the sampling frame for Part I consisted of patients over a 14 day period, whereas Part II covered patients over a 31 day period. However the method of random selection o f patients from each sampling frame ensured that both samples selected were representative of the patients under investigation and also ensured that no selection bias was introduced. In addition, because of the different timings of the two sampling frames, the maximum time between discharge and receiving a questionnaire for the two parts was slightly different (four weeks versus six weeks). This may have introduced a differential recall bias but this is likely to have been very small and is very unlikely to affect the overall results and conclusions. Although the original reason for suggesting a change in policy was financial (about £40,000 savings per year) it was noted that some Health Authorities already operated
Hospital Discharge Medication
247
successful seven day policies. For example in the Trent Region, District policies ranged from 14 days supply to no supply at all. It is difficult to understand how this latter policy could operate successfully without extreme hardship to patients. In these days o f cost improvements and financial hardships, District Health Authorities need to look closely at the effect any change in policy has on patient care. This study has shown that as long as the discharge letter has prescription details on it and is delivered by hand, seven days supply o f medication has no detrimental effect on patient care. It is likely that the speed o f delivery and quality of information on discharge letters are more important factors than the n u m b e r o f days medication supplied, although seven days is probably optimal.
Acknowledgements I would like to thank Dr L. M. Davies, Dr S. M. Whitehead, Dr J. Grenville, Mr M. Cullen and Professor R. Madeley for their help in the preparation of this paper, and Mrs J. Bridge for typing the manuscript.
References 1. Tulloch, A. J., Fowler, G. H., McMullan, J. J. & Spence, J. M. (1975). Hospital discharge reports: content and design. British Medical Journal, 4, 443~146. 2. Mageean, R.J. (1986). Study of 'discharge communications' from hospital. British Medical Journal, 293, 1283-1284. 3. Sandler, D.A. & Mitchell, J. R. A. (1987). Interim discharge summaries: How are they best delivered to general practitioners? British Medical Journal, 295, 1523-1525. 4. Dover, S. B. & Low Beer, T. S. (1984). The initial hospital discharge note: send out with the patient or post? Health Trends, 16, 48. 5. Kendrick, A. R. & Hindmarsh, D. J. (1989). Which type of hospital discharge report reaches General Practitioners most quickly? British Medical Journal, 298, 362-363 6. Penney, T. M. (1988) Delayed communication between hospitals and general practitioners: where does the problem lie? British Medical Journal, 297, 28-29. 7. Long, A. & Atkins, J. B. (1974). Communications between General Practitioners and Consultants. British Medical Journal, 4, 456~59. 8. Harding, J. (1987). Study of discharge communications from hospital doctors to an inner London General Practice. Journal of the Royal College of General Practitioners, 37, 494-495.
