Dismissal disagreement and discharge delays: Associations of patient-clinician plan of care agreement with discharge outcomes

Abstract

Background: Many hospitalized patients do not understand or agree with their clinicians about their discharge plan. However, the effect of disagreement on discharge outcomes is unknown.

Objective: To measure the correlation between patient-clinician care agreement and discharge outcomes.

Design: A prospective cohort study was performed from September 2019 to March 2020 (Rochester, MN, USA).

Setting and participants: Internal medicine patients and their primary clinician (resident, advanced practice clinician or attending) hospitalized from September 2019-March 2020 at Mayo Clinic Hospital. Participants were independently surveyed following hospital day #3 ward rounds regarding the goals of the hospitalization and discharge planning.

Main outcome and measures: Patient-clinician agreement for main diagnosis, patient's main concern, and four domains of discharge planning was assessed. Readiness for hospital discharge, delayed discharge, and 30-day readmission was measured. Then, associations between patient-clinician agreement, delayed discharge, and 30-day readmissions were analyzed using multivariable logistic regression.

Results: Of the 436 patients and clinicians, 17.7% completely agreed about what needs to be accomplished before dismissal, 40.8% agreed regarding discharge date, and 71.1% agreed regarding discharge location. In the multivariable model, patient-clinician agreement scores were not significantly correlated with discharge outcomes. Patient-clinician agreement on discharge location was higher for those discharged to home (81.5%) versus skilled nursing facility (48.5%) or assisted living (42.9%) (p < .0001). The agreement on the expected length of stay was highest for home-goers (45.9%) compared to skilled nursing (32.0%) or assisted living (21.4%) (p = .004).

Conclusions: Patients and their clinicians frequently disagree about when and where a patient will go after hospitalization, particularly for those discharged to a skilled nursing facility. While disagreement did not predict discharge outcomes, our findings suggest opportunities to improve effective communication and promote shared mental models regarding discharge earlier in the hospital stay.