Improving best practice for patients receiving hospital discharge letters: a realist review

OBJECTIVE: To understand how different outcomes are achieved from adult patients receiving hospital discharge letters from inpatient and outpatient settings. DESIGN: Realist review conducted in six main steps: (1) development of initial theory, (2) searching, (3) screening and selection, (4) data extraction and analysis, (5) data synthesis and (6) programme theory (PT) refinement. ELIGIBILITY CRITERIA: Documents reporting evidence that met criteria for relevance to the PT. Documents relating solely to mental health or children aged <18 years were excluded. ANALYSIS: Data were extracted and analysed using a realist logic of analysis. Texts were coded for concepts relating to context, mechanism, outcome configurations (CMOCs) for the intervention of patients receiving discharge letters. All outcomes were considered. Based on evidence and our judgement, CMOCs were labelled ‘positive’ or ‘negative’ in order to clearly distinguish between contexts where the intervention does and does not work. RESULTS: 3113 documents were screened and 103 were included. Stakeholders contributed to refining the PT in step 6. The final PT included 48 CMOCs for how outcomes are affected by patients receiving discharge letters. ‘Patient choice’ emerged as a key influencer to the success (or not) of the intervention. Important contexts were identified for both ‘positive’ CMOCs (eg, no new information in letter) and ‘negative’ CMOCs (eg, letter sent without verifying patient contact details). Two key findings were that patient understanding is possibly greater than clinicians perceive, and that patients tend to express strong preference for receiving letters. Clinician concerns emerged as a barrier to wider sharing of discharge letters with patients, which may need to be addressed through organisational policies and direction. CONCLUSIONS: This review forms a starting point for explaining outcomes associated with whether or not patients receive discharge letters. It suggests several ways in which current processes might be modified to support improved practice and patient experience.