BJD

British Journal of Dermatology

R EV IE W AR TI C LE

The dermatology outpatient discharge decision: understanding a critical but neglected process* N.A. Harun,1,2 S. Salek,1 V. Piguet2 and A.Y. Finlay2 1

Centre for Socioeconomic Research, Cardiff School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff CF10 3NB, U.K. Department of Dermatology and Wound Healing, Cardiff University School of Medicine, Cardiff University, 3rd Floor, Glamorgan House, Heath Park, Cardiff CF14 4XN, U.K. 2

Summary Correspondence Nur Ainita Harun. E-mails: [email protected] and finlayay@ cf.ac.uk

Accepted for publication 3 January 2014

Funding sources No external funding.

Conflicts of interest None declared. *Plain language summary available online DOI 10.1111/bjd.12826

Discharge from dermatology outpatients is a critical endpoint of patient care. Despite this, there has been very little research concerning the discharge process and factors influencing the discharge decision. To identify the factors influencing discharge decisions, articles from 1970 to April 2013 were searched in MEDLINE via Ovid, CINAHL, PROQUEST and Google Scholar using the keywords ‘patient discharge’, ‘discharge decision’, ‘factors influencing discharge’, ‘clinical decision making’, ‘discharge decision making’, ‘process of discharge decision’, ‘outpatient’, ‘follow up’, ‘skin disease’ and ‘dermatology’. Only articles describing outpatient discharge decisions were included. Seventeen outpatient discharge articles were identified, 12 from the U.K. (seven dermatology) and five from the U.S.A., Canada, Australia and Taiwan (all nondermatology). The main influences on outpatient discharge identified were diagnosis and disease severity, clinician’s level of experience and perception, patient’s preferences, patient’s behaviour and quality of life. These influences affected the clinician’s judgement on discharge decisions both in appropriate and in inappropriate ways. Little is known concerning discharge decision making in dermatology. Given the central importance of such decisions in the appropriate care of patients and the efficient running of any dermatology service, greater understanding of the influences on discharge decision making is needed. It is therefore critical for dermatologists to be aware of these influences and to ensure that decisions are taken only in the best interests of patients. Further research is required to inform the training of dermatologists on how to take the most appropriate discharge decisions.

What’s already known about this topic?

• •

Discharge decision making is a complex and critical process. There is no defined strategy on how to carry out an appropriate discharge in the dermatology outpatient setting.

What does this study add?

• • •

Influences on discharge decision making relate to disease, clinician, patient and practice setting. The clinician’s judgement plays a central role in discharge decision making and needs further exploration. Intuition and bias influence the process of discharge decision making.

One of the most frequent and complex decisions a clinician has to make is whether or not to discharge a patient.1–8 The term ‘discharge’ can be applied to several different situations,

including absolute discharge of inpatients or outpatients, and conditional discharge, where the patients may have the option of open-access return either for a limited or extended period

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1030 Outpatient discharge decision in dermatology, N.A. Harun et al.

of time. In this review we have concentrated on discharge from dermatology outpatient clinics, with or without openaccess return. Discharge is the critical endpoint of patient care in the outpatient clinical setting. However, there has been little investigation of this aspect of outpatient clinical practice, or of the special factors of concern to patients with skin diseases such as chronicity or psychosocial aspects. There are very high numbers of attendances at dermatology outpatient clinics.9,10 Dermatology was identified as a key specialty needing transfer of healthcare from the hospital setting to community care.11 In England, dermatologists are encouraged to increase their outpatient discharge rates in order to meet ‘new to follow up’ ratios;12,13 however, there is little guidance on how to carry this out. Essentially, the aim is to maximize capacity for receipt of new referrals and this requires current patients to be discharged. The target ‘new to follow up’ ratio is set by managers at a level that has the smallest number of follow up patients possible while avoiding overt patient risk. Discharge decision making is ethically sensitive;14 the Salzburg Statement on shared decision making called on clinicians to be morally responsible in sharing important decisions which should be clear and evidence based.15 Little is known concerning how discharge decisions are taken in general medical or dermatology outpatients. The aim of this review was to identify the influences on outpatient discharge decision making.

Methods A literature search from 1970 to April 2013 was carried out using Medline, Embase, PsycINFO on Ovid, CINAHL, PROQUEST and Google Scholar. Key search terms were ‘patient discharge’, ‘discharge decision*’, ‘factors influencing discharge*’, ‘clinical decision making’, ‘discharge decision making’, ‘process of discharge decision’, ‘outpatient*’, ‘follow up*’, ‘skin disease’ and ‘dermatology’ (Table 1). Studies were included only if factors influencing the discharge decisionmaking process were discussed. Non-English articles and articles concerning mental health, paediatrics, obstetrics and

emergency settings were excluded except for one.16 In this review, the term ‘clinician’ refers also to nurses and therapists. Each article was examined using a standardized template to record factors influential on the discharge decision. The factors were categorized into influences related to disease, clinician, patient and practice.

Results Seventeen3–8,16–26 outpatient discharge articles were identified of which seven concerned dermatology.5–7,19,24–26 Fourteen described prospective studies,3–8,17–22,25,26 two described retrospective studies16,24 and one described general views23 of the clinicians (Table 2). Major clinical influences included diagnosis and disease severity. Nonclinical influences included clinician, patient, practice and policy-related factors as described below. The influences on discharge decision making are summarized in Figure 1. Disease-related factors Diagnosis and severity of skin disease were the main influences on whether or not a patient is discharged.5,7,19,24–26 For example, following an audit of basal cell carcinoma follow up it was proposed that follow up plans should be based on clinical features of the tumour, the complexity of surgery and on whether the patients had an organ transplant.24 Patients with uncomplicated excisions were 70% more likely to be discharged than patients with complicated excisions.24 Similarly, a high proportion of patients with benign lesions were discharged after the first visit.19,25 In general, diseases that are ‘cured’ are obviously more likely to be discharged and usually will not need any arrangements for further follow up in the primary care setting.3 A major influence on discharge decisions was if patients were asymptomatic or had self-limiting disease.5 The stability of patients’ vital signs, their orientation and alertness were the main factors determining surgical outpatient discharge readiness.22 Nonclinical influences such as medical intuition or

Table 1 Key search terms Patient discharge

Decision making

Dermatology

Patient discharge/ Discharg* adj2 patient* [(Patient* or client) adj3 (discharg*)] Discharge*.tw. Outpatient* Follow up*

Explode ‘decision making’/all subject headings Decision making.tw. Discharge decision making.tw. Discharge decision* Process of discharge decision Discharge process Discharge* adj3 decision* adj3 process Clinical decision making Factors influencing adj2 discharge

Dermatology.tw. Dermatolog* Skin.tw. Explode Skin disease/

AND

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AND

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© 2014 British Association of Dermatologists

U.K.: General surgery

U.K.: General medical and surgical

Faulkner (1995)20

Burkey (1997)4

Hughes (2003)21

a Finlay (2000)5

U.K.: Cardiology

U.K.: General medical and surgical including dermatology

U.K.: Dermatology, Rheumatology, Vascular surgery U.K.: Rheumatology and Vascular surgery

Sullivan (1992)19

Sullivan (1993)3

Country: specialty

First author (year)ref

Physicians of all grades

Prospective (clinical vignette)

Prospective (questionnaire)

Prospective (observation and interviews)

Prospective (observation and interview)

Physicians

Physicians and surgeons

Physicians

Surgeons

Physicians, patients and GPs

Prospective (questionnaire)

Prospective (questionnaire)

Participants

Design

Disease at GP management stage Disease selflimiting Disease needing GP care Diagnosis firm Medication Symptoms assessment

Diagnosis Cured Disease not within specialty Disease severity

Diagnosis Disease severity

Clinical influences Disease-related

Habits of retaining patients

Uncertainties about GP care Perception about their role and responsibilities Feelings of guilt for discharging

Expertise Staff grade

Physician-related

Nonclinical influences

Asymptomatic

Feelings of loss

GP’s capability to follow up GP’s interest in following up Patient study completed

Age Recurrent defaulter Wishes not to be followed up Wishes to be seen by GP Attending other clinics Distance to clinic

Discharge preparation time constraint Discharge plan availability Nurse-led clinics availability

Routine follow-up practice Poor discharge arrangement Additional paperwork Communication difficulties with GP

Hospital equipment and facilities

Practice-related

Age Employment Wishes

Patient-related

Clinic policy

Policy-related

Table 2 Study characteristics and factors influencing discharge decisions in outpatient dermatology and other outpatient settings (17 studies: 14 prospective, two retrospective and one general review)

Outpatient discharge decision in dermatology, N.A. Harun et al. 1031

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British Journal of Dermatology (2014) 170, pp1029–1038

U.K.: Dermatology

U.K.: Dermatology

Hajjaj (2010)7

Hajjaj (2010)6

Canada: Orthopaedic physiotherapy

Pashley (2010)8

Prospective (interviews)

Prospective (observation and interviews)

Prospective (interviews)

Dermatologists

Patients

Physiotherapists

General internists and family physicians

U.S.A.: General medicine and family medicine

Farber (2008)17

Prospective (questionnaires of hypothetical scenarios)

U.S.A.: Surgery

Kingdon (2006)22

General practitioner and patients

Nurses

Prospective (postal survey)

U.K.: General practice

Sampson (2004)18

Participants

Prospective (Delphi technique)

Design

Country: specialty

First author (year)ref

Table 2 (continued)

Diagnosis Disease at GP management Disease chronicity Skin condition

Clinical progress such as quality of gait Disease chronicity

Symptoms assessment

Clinical influences Disease-related

Staff grade Perception that discharge preparation is consuming

Expertise Confidence Ability to negotiate Ability to balance preferences and funding constraints Ability to educate Ability to quantifying clinical progress Staff grade Senior physician’s advice Consultant’s presence Perceived patient’s nonadherence

Intuition Education Experience Personal belief Age

Deteriorating relationships with patients

Physician-related

Nonclinical influences

Noncompliance to medication Rude behaviour

Quality of life Wishes Relatives and friends

Demanding behaviour Noncompliance Missed appointments Nonpayment Alcoholic Falsifying prescriptions Attitudes towards funding limitation Attitude towards chronicity of their disease Ability to self-manage

Abusive behaviour Noncompliance Drug abuse Complaint or litigation Inappropriate demand for treatment Family support

Patient-related

Private practice Limited services or medical resources

Clinical guidelines

Limitations set by insurers

Limited medical resources

Poor communication

Practice-related

Policy-related

1032 Outpatient discharge decision in dermatology, N.A. Harun et al.

© 2014 British Association of Dermatologists

© 2014 British Association of Dermatologists

a

a

U.K.: Dermatology

Abstract. GP, general practitioner.

Foley (2012)25

Taiwan: Emergency department

Wu (2012)16

U.K.: Dermatology

Australia: Speech and language therapy

U.K.: Dermatology

Salek (2012)26

23

Country: specialty

Poirier (2012)24

a

Hersh (2010)

First author (year)ref

Table 2 (continued)

Prospective

Retrospective

Retrospective (audit)

Prospective (interviews)

General literature review

Design

Emergency physicians

Clinic practice

Dermatologists of all staff grades (22)

Speech and language pathologists

Participants

Diagnosis

Diagnosis Diagnosis manageable at primary care level Type of treatment Skin condition Diagnosis

Clinical influences Disease-related

Uncertainty of patient’s wishes Staff grade

Awareness pertaining to discharge Attachment to the patient Coping with their emotions such as sadness Retaining professional control over discharge Confidence Communicative skills Experience Fear of litigation

Physician-related

Nonclinical influences

Age Wishes

Self-care skills Difficult acceptance of discharge among patients and their families Level of autonomy

Patient-related

Job pressure Commissioning practices Coordination of care

Waiting list pressure

High case load pressures Limited medical resources Community support and services availability

Practice-related

Local policy

Policy emphasis on early discharge

Policy-related

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1034 Outpatient discharge decision in dermatology, N.A. Harun et al.

Practice factors

Individual factors

• Pracce paern (20,25)

• Clinician's personality/values/beliefs (18,21–23,26)

• Clinical guideline (7) • High case load (23,24,26) • Resource availability (3,6,17,19,21,23) • GP or primary care support (19)

Policy factors • Payer organizaon (8) • Healthcare policies (21,26)

• Clinician's percepon of paents(4,7) • Clinician intra-and interprofessional collaboraon/ communicaon (18)

Individual factors • Paent’s wishes (3,7,19,26) • Paent’s behaviour (6,8,17,18) • Paent’s socioeconomic status (19) • Paent’s quality of life (7) • Paent’s age (7,19,26) • Paent’s geographical

Practice factors • Resource availability (3,6,17,19,21,23)

locaon (3) Shared decision making Clinical experience and knowledge (2,8,22,26) and grade of staff (6,7,16,19)

Clinician's self-awareness (23)

Patient’s decisional capacity

Diagnosis (5,7,8,24–26) and disease severity (3,19)

Ethics (14) Decision bias (44,45) Intuition (22) Clinician's judgement (2,14)

Family and carer involvement (7,22)

Communication/Collaboration/ Confidence Informaon sharing Dealing with opons and uncertaines Goal seng Negoang Agreeing on course of acon

Discharge decision

Fig 1. Summary of influences on discharge decision making. GP, general practitioner. Reference numbers in brackets.

experience were important but less influential.22 The chronicity of a skin disease had an influence on discharge decisions. Patients with recalcitrant skin problems were more likely to be discharged.7 Whether a skin condition is manageable at primary care level was a discriminating factor5 influencing discharge decisions. However, this influence was noted only twice in the observation of 61 dermatology outpatient consultations.7

to discharge due to fear of litigation.26 Educating junior doctors on appropriate discharge may improve discharge rates.26 However, a small U.K. qualitative study did not find any difference in discharge practice between senior and junior doctors.5 In emergency departments, senior clinicians were more cautious in discharging patients than junior doctors.16 The clinician’s intuition or ‘gut feelings’

Clinician-related factors The clinician’s experience and expertise In a UK study, 68% of dermatologists considered clinical experience as the most important factor governing their discharge decisions.26 Similarly, in Canada, physiotherapists considered clinical experience as the most important factor governing their discharge decisions.8 Their confidence level and clinical judgement in discharging patients improved with experience. The perceived need for consultant supervision and expertise was the most important reason for continued clinic attendance given by dermatology patients.3,19 The clinician’s level of seniority The discharge rates were higher among senior clinicians than juniors.6,17,19,26 In a U.K. study the discharge rate of consultant dermatologists was 48%, clinical assistants 29% and senior house officers 0%.19 Junior doctors discharged less in the absence of a senior clinician’s advice3,7 and were less confident British Journal of Dermatology (2014) 170, pp1029–1038

When a clinician describes their ‘gut feeling’ about a patient, they are describing one aspect of clinical judgement that may not be easily articulated, but which most clinicians would respect as a valid reflection of the reality of clinical practice. It may, appropriately, involve risk avoidance. Protocols and clinical guidelines must always be subservient to the clinicians’ judgement of what is best for that particular patient at that time.6 In the outpatient surgery setting in the U.S.A., nurses acted on their ‘gut feelings’ or ‘medical intuition’ in determining patient readiness for discharge as well as mainly considering patients’ clinical symptoms and signs post-surgery.22 Although not considered an important influence, it was incorporated in a ‘final discharge assessment’ which was developed for outpatient surgical patients.22 The clinician’s personality The clinician’s personality traits can influence clinical decision making.16 Speech and language therapists who have ‘softer’ personality characteristics put much energy into negotiating © 2014 British Association of Dermatologists

Outpatient discharge decision in dermatology, N.A. Harun et al. 1035

discharge with long-term patients.23 Some clinicians also struggle with guilt in discharging patients who have been on long-term follow up.4 Others, however, may feel no qualms on discharging such patients.6,17,18 Physicians develop the art of negotiating with patients,8 while maintaining professionalism23 as well as exercising ethical awareness23 upon discharging patients. Discharge decision making may be complicated by uncertainties in patient’s wishes16 adding to the need for skilful judgement.

of the patient’s QoL on discharge and other management decisions was mentioned twice as often during interviews with patients as was noted in observing consultations,7 suggesting that insufficient QoL discussion takes place during dermatology consultations.27 Training clinicians to enquire about QoL issues or the use of a patient QoL measure might improve the appropriateness of a clinician’s decision making.28 The patient’s socioeconomic and functional status

The clinician’s perceptions The clinician’s perceptions of the circumstances surrounding a discharge are an important influence on discharge decision making.3,4 Major influences are the clinicians’ perception of being more competent than their general practitioner (GP) colleagues and the perception of their role in outpatient care.3,4 Other influences include the perception of the need for more secondary intervention21 and whether the disease can be managed at a primary care level.5,26 Dermatologists would continue to follow up patients if they perceived a lack of patient adherence to medication.7 In a U.K. study, surgeons continued to follow up patients, such as those with breast cancer, as they felt they traditionally needed routine follow up.20 Some clinicians did not discharge patients in order to avoid the additional perceived workload involved in discharge.4 Patient-related factors

The patient’s age,7,19,26 employment status19 and home accessibility3 may influence discharge decisions. Elderly patients had lower discharge rates whereas patients who were employed were more likely to be discharged.19 The patient’s ability to self-manage Patients’ ability to mobilize and self-care influence discharge rates among rehabilitation patients.8 Practice-related factors Practice patterns High waiting list26 and caseload pressure23 influenced discharge decisions between dermatologists in the U.K. and speech and language therapists in Australia.

The patient’s behaviour

Resource constraints

Patient behaviour may influence dermatologists’ discharge decision making.6 Fifty-two per cent of dermatologists would discharge rude or demanding patients earlier than expected or refer them for a second opinion.6 Similarly, in a U.K. study, 64% of GPs reported that they would remove patients from their list if they were violent or abusive.18 In a U.S.A. study using hypothetical scenarios, 40% of primary care physicians and general internists stated they would discharge patients if they were verbally abusive or violent.17 Clinicians would discharge patients if they were nonadherent to medication and appointments.3,17,18 However, dermatologists in Wales stated they would arrange additional follow up appointments to improve treatment adherence.7

Limited funding for physiotherapy services may reduce the number of treatment sessions and might result in early discharge.8 However, this restriction may encourage patients to take their treatment plan more seriously and promote faster recovery.8 It is possible that there may be differences in discharge ratios in private self-pay settings vs. other settings. In U.K. private practice, fewer follow ups occur than in the NHS, in order to reduce patient costs.6 Most dermatologists felt pressured to discharge patients due to long waiting lists to be seen in their clinics26 and 4% of junior physicians would not discharge patients because they considered preparing discharge letters time consuming.6 General practitioner or community care support

The patient’s preferences or expectations Clinicians including dermatologists would consider patients’ wishes if the patient decided to be discharged.7,19,26 However, many clinicians find difficulty in balancing conflicts between patient autonomy and the availability of resources to support discharge.8 The patient’s quality of life The patient’s quality of life (QoL) is an important nonclinical influence on discharge in dermatology.7 The influence © 2014 British Association of Dermatologists

The level of interest, capability19 and availability of a GP4 or nurse-led clinic21 can facilitate earlier discharges avoiding unnecessary follow up. Policy-related factors A clinic policy encouraging early discharge influenced discharge practices between speech and language therapists in Australia.23 Payer organization requirements may influence discharge decisions among dermatologists in the U.K.24 British Journal of Dermatology (2014) 170, pp1029–1038

1036 Outpatient discharge decision in dermatology, N.A. Harun et al.

Discussion We have previously identified the complex range of influences on clinical decision making in dermatology outpatients, which include clinical disease-related influences and nonclinical influences relating to patient, clinician and to practice (Fig. 1).29 These include widely varying issues such as how far the patient lives from the hospital,3 the personality of the clinician4,8,16,18,21–23 and the QoL impairment7 of the patient. All these factors may be taken into account when deciding between discharge or further follow up: the decision to discharge is essentially the same decision, or at least the other side of the same coin, as the decision to follow up, although sometimes influences to discharge may predominate, and sometimes influences to follow up may predominate. The goal of a quality discharge process is to integrate the appropriate influences and minimize inappropriate nonclinical influences, preferably in a structured manner. It occurs in an ethical framework that requires the art of integrating evidence-based medicine and nonclinical influences29 including the patient’s preferences. Although dermatologists and other practitioners consider these factors in the discharge decision-making process, two major gaps exist in the literature. Firstly, the nature of the outpatient discharge decision-making process and how it unfolds in relation to these influential factors has yet to be explored. Previous studies have focused on improving the overall discharge planning and process,8,30 discharge preparation31 and the outcome of patient discharge.32 The inpatient discharge process involves three main steps: the process of discharge decision making, the process of discharge preparation and the process of handing over the patient to the next care service.31 This process follows a dynamic and fluid sequence that starts from admission until leaving the hospital2 and a number of factors influence this process including negotiation between the clinician, patients and the GP or community care provider.1,8 In contrast, the outpatient discharge decision process hinges to a great extent on the individual clinician’s choice during the clinic consultation rather than on prolonged discussions involving a team of healthcare providers. Secondly, very little is known about the clinicians’ thought processes on how they arrive at an outpatient discharge decision. The clinician serves as a (hopefully) ethically responsible conduit of clinical reasoning whereby a network of intricate influences is funnelled through his or her thought processes prior to making a judgement on discharge decision. How these influences are moulded, interpreted or judged, depends very much on the clinician’s sense of confidence, self-awareness and perception of the circumstances surrounding the discharge process, the patient’s decisional capacity and finally the effectiveness of communication and extent of trust in the physician–patient relationship. Clinical judgement is the cognitive arm of the decisionmaking process,33 and fostering this, is central to high-quality and appropriate discharge. Judgement is a process of integrating external information34,35 or internal information, i.e. from British Journal of Dermatology (2014) 170, pp1029–1038

memory,36 and decision analysis involving different options and using causal reasoning, i.e. consideration of the situation,37 to make a single evaluation.36,38 Therefore, it may be reasonable to assume that the clinician’s ability to judge will influence the accuracy of his or her decision making, hence the importance of good judgements.39 A good judgement is rational and clear with maximum certainty despite any conflicting or unavailable information. This review has demonstrated that, along with clinical experience, clinicians use at least two elements of judgement40 when making discharge decisions. These elements include intuitive judgement22 and patient-aided judgement.7,8 One study has highlighted clinicians’ use of medical intuition informing their discharge decisions.22 Intuition is based on a dual process of a nonconscious, automatic approach and a conscious, analytical approach,38 ranging from deciding on what first comes to mind to an experience-based intuition.41,42 Clinicians use their medical intuition or gut feelings to make decisions22 but the introduction of evidence-based medicine has encouraged a more scientific approach.29 The right clinical decision is not always the right moral decision.43 Similarly, the right discharge decision is not always morally correct. Discharging patients who are noncompliant to medication might increase the clinician’s consultation time available for other patients, but this would not be compatible with the applicable Code of Ethics.17 There are various schools of thought regarding models of healthcare, including the utilitarian approach which incorporates the philosophy that with a limited resource one should do the greatest good for the greatest number. This approach may influence clinical decision making with regard to an individual patient.23 In a system such as the NHS in the U.K., this context may provide further influence, emphasizing the importance of the local framework of care provision and efficient use of resources. This review has revealed that clinicians face many difficulties when making discharge decisions while attempting to balance patients’ needs and appropriate use of healthcare resources. For example, in Canada, patients had to be discharged because of job pressures, or because third-party payers or insurance companies had restricted further payment for follow up treatment,8 occasionally overriding both the clinician’s and the patient’s preferred decision. Clinicians oversimplify decision making by using heuristic principles or mental shortcuts44 when confronted with uncertainties in decisions such as discharge. Judgement under uncertainty may be the explanation for the variation in discharge practice between dermatologists in Wales;26 besides considering patients’ clinical outcome, some clinicians might have the tendency to discount nonclinical factors such as a patient’s inconvenience, short-term risks or overall healthcare cost while others do not. Decisions made under stress and with uncertainties, as in a busy outpatient dermatology clinic, require an awareness of such biases,44,45 hence the need for evidencebased decision analysis tools.46 The same mistakes in the decision-making process, termed ‘decision traps’, such as overconfidence, are often repeated in various professions.47 © 2014 British Association of Dermatologists

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Although previous research has proposed possible strategies for improving outpatient discharge practices in general,4,5,8,22,48 few studies have concentrated on dermatology. Further empirical research is needed in order to understand how to improve discharge decision making in outpatient dermatology practice. In order to provide coherence to the topic, and before we can give a reader guidance as to how to review their own practice we need to understand the influences on discharge decisions in much more detail. This will require qualitative studies of dermatologists’ attitudes and current practice. Such prospective information would provide the basis for identifying strategies that clinicians could use to achieve appropriate and timely discharge decisions. Professionals and patients may benefit from educational programmes7,49 that focus on understanding critical discharge factors5 and about inappropriate influences, hopefully leading to better clinical judgement concerning discharge decisions.45 There may also be benefits in educating patients about the discharge decision process. Our review highlights that currently available information about discharge decision making in dermatology outpatients is inadequate to draw any conclusion as to how discharge decision making should be approached in the NHS. We are therefore currently undertaking prospective studies in this area. More influences on discharge decisions may have been identified if the literature search had included other disciplines such as mental health. The review concentrated mainly on the views of clinicians, but did not specifically search for views of patients, carers or primary care providers. The exclusion of non-English articles may have resulted in some information being missed. Outpatient discharge decision making is complex. Beyond diagnosis and disease severity, there is a wide array of nonclinical factors. Our personal impression is that the onus is on the clinician to ensure that these nonclinical influences take appropriate precedence in the discharge decision-making process. These influences include the clinician’s experience, personality, medical intuition and perception. Patient-related factors include the patient’s behaviour, quality of life and wishes. Prospective studies are required to develop strategies and training methods to improve the quality of discharge decision making. If dermatologists better understood how discharge decisions are carried out, more appropriate outpatient discharge decisions might be achieved, in the best interests of patients and dermatology services.

References 1 Armitage SK. Negotiating the discharge of medical patients. J Adv Nurs 1981; 6:385–9. 2 Jewell SE. Discovery of the discharge process: a study of patient discharge from a care unit for elderly people. J Adv Nurs 1993; 18:1288–96. 3 Sullivan FM. How do clinicians decide to discharge someone from their out-patient clinic? J Manag Med 1993; 7:24–8. 4 Burkey Y, Black M, Reeve H et al. Long-term follow-up in outpatient clinics. 2: the view from the specialist clinic. Fam Pract 1997; 14:29–33. © 2014 British Association of Dermatologists

5 Finlay AY, Davies RW, Cosker TDA et al. Factors influencing outpatient discharge. Br J Dermatol 2000; 143 (Suppl. 57):42–85. 6 Hajjaj FM, Salek MS, Basra MKA et al. Nonclinical influences, beyond diagnosis and severity, on clinical decision making in dermatology: understanding the gap between guidelines and practice. Br J Dermatol 2010; 163:789–99. 7 Hajjaj FM, Salek MS, Basra MK et al. Clinical decision making in dermatology: observation of consultations and the patients’ perspectives. Dermatology 2010; 221:331–41. 8 Pashley E, Powers A, McNamee N et al. Discharge from outpatient orthopaedic physiotherapy: a qualitative descriptive study of physiotherapists’ practices. Physiother Can 2010; 62:224–34. 9 National Health Service. Hospital Episode Statistics for England. Outpatient statistics, 2011–12. Main specialty by age group for all outpatient attendances. The Health and Social Care Information Centre, 2012. Available at: http://www.hscic.gov.uk/catalogue/ PUB09379/hosp-outp-acti-11-12-all-atte-tab.xls (last accessed 19 February 2014). 10 Donnellan F, Hussain T, Aftab AR et al. Reducing unnecessary outpatient attendances. Int J Health Care Qual Assur 2010; 23:527–31. 11 Roland M, McDonald R, Sibbald B. Can Primary Care Reform Reduce Demand on Hospital Outpatient Departments? Research Summary. London: NHS Service Delivery and Organisation R&D Programme, 2007. 12 Schofield J, Grindlay D, Williams H. Skin Conditions in the UK: A Health Care Needs Assessment. Nottingham: University of Nottingham, Centre of Evidence Based Dermatology, 2009. 13 Hill G, Sowden J, Lister R et al. Dermatology outpatient case-mix survey for all Welsh Trusts, 2007. Br J Dermatol 2010; 162:152–8. 14 Chadwick R, Russell J. Hospital discharge of frail elderly people: social and ethical considerations in the discharge decision-making process. Ageing Soc 1989; 9:277–95. 15 Salzburg Global Seminar. Salzburg statement on shared decision making. BMJ 2011; 342:d1745. 16 Wu K-H, Chen IC, Li C-J et al. The influence of physician seniority on disparities of admit/discharge decision making for ED patients. Am J Emerg Med 2012; 30:1555–60. 17 Farber NJ, Jordan ME, Silverstein J et al. Primary care physicians’ decisions about discharging patients from their practices. J Gen Intern Med 2008; 23:283–7. 18 Sampson F, Munro J, Pickin M et al. Why are patients removed from their doctors’ lists? A comparison of patients’ and doctors’ accounts of removal. Fam Pract 2004; 21:515–18. 19 Sullivan FM, Hoare T, Gilmour H. Outpatient clinic referrals and their outcome. Br J Gen Pract 1992; 42:111–15. 20 Faulkner A, Saltrese-Taylor A, O’Brien J et al. Outpatients revisited: subjective views and clinical decisions in the management of general surgical outpatients in south west England. J Epidemiol Community Health 1995; 49:599–605. 21 Hughes ML, Leslie SJ, McInnes GK et al. Can we see more outpatients without more doctors? J R Soc Med 2003; 96:333–7. 22 Kingdon B, Newman K. Determining patient discharge criteria in an outpatient surgery setting. AORN J 2006; 83:898–904. 23 Hersh D. I can’t sleep at night with discharging this lady: the personal impact of ending therapy on speech-language pathologists. Int J Speech Lang Pathol 2010; 12:283–91. 24 Poirier V, Osinowo A, Takwale A et al. Basal cell carcinoma follow-up in the South West, Hampshire and Isle of Wight; Bristol Cup Posters: Poster P88, presented at: British Association of Dermatologists 92nd Annual Meeting, Birmingham, 3–5 July 2012. Br J Dermatol 2012; 167 (Suppl. S1):21–69. 25 Foley C, Corby P, Barnes L. A dermatology outpatient list initiative. Poster P-03, presented at: Irish Association of Dermatologists Spring Meeting, Dublin, 27 April 2012. Br J Dermatol 2012; 167:e26–37.

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1038 Outpatient discharge decision in dermatology, N.A. Harun et al. 26 Salek MS, Siyani S, Basra MK et al. The clinical and non-clinical factors influencing discharge decisions in dermatology: is there a need for discharge strategy? Int J Clin Pharm 2012; 34:178–9. 27 David SE, Ahmed Z, Salek MS et al. Does enough quality of liferelated discussion occur during dermatology outpatient consultations? Br J Dermatol 2005; 153:997–1000. 28 Finlay AY. Practice Gaps. Dermatologists should better integrate quality-of-life measures to inform and improve clinical decision making: comment on ‘The impact of pruritus on quality of life’. Arch Dermatol 2011; 147:1157. 29 Hajjaj FM, Salek MS, Basra MKA et al. Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice. JRSM 2010; 103:178–87. 30 Grimmer K, Dryden L, Puntumetakul R et al. Incorporating patient concerns into discharge plans: evaluation of a patient-generated checklist. J Allied Health 2006; 4:2. 31 Lin F, Chaboyer W, Wallis M. A literature review of organisational, individual and teamwork factors contributing to the ICU discharge process. Aust Crit Care 2009; 22:29. 32 Burkey Y, Black M, Reeve H. Patients’ views on their discharge from follow up in outpatient clinics: qualitative study. BMJ 1997; 315:1138–41. 33 Bazerman MH. Judgement in Managerial Decision Making, 5th edn. New York: John Wiley & Sons, Inc., 2002. 34 Harte JM, Koele P. Modelling and describing human judgement processes: the multiattribute evaluation case. Think Reason 2001; 7:29–49. 35 Dhami MK, Harries C. Fast and frugal versus regression models of human judgement. Think Reason 2001; 7:5–27. 36 Maule AJ. Studying judgement: some comments and suggestions for future research. Think Reason 2001; 7:91–102. 37 Smith PT, McKenna F, Pattison C et al. Structural equation modelling of human judgement. Think Reason 2001; 7:51–68.

British Journal of Dermatology (2014) 170, pp1029–1038

38 Betsch T. The nature of intuition and its neglect in research on judgment and decision making. In: Intuition in Judgment and Decision Making (Plessner H, Betsch T, Betsch C, eds). Abingdon, Oxon: Lawrence Elbaum Associates, Taylor & Francis, 2008; 3–22. 39 Dowding D, Thompson C. Using judgement to improve accuracy in decision-making. Nurs Times 2004; 100:42. 40 Standing M. Clinical judgement and decision-making in nursing – nine modes of practice in a revised cognitive continuum. J Adv Nurs 2008; 62:124–34. 41 Aldrich N, Mostow E. Incorporating teaching dermatoethics in a busy outpatient clinic. J Am Acad Dermatol 2011; 65:423–4. 42 Woolley A, Kostopoulou O. Clinical intuition in family medicine: more than first impressions. Ann Fam Med 2013; 11:60–6. 43 Devettere RJ. Practical Decision Making in Healthcare Ethics, 3rd edn. Washington, DC: Georgetown University Press, 2010. 44 Tversky A, Kahneman D. Judgment under uncertainty: heuristics and biases. Utility, Probability, and Human Decision Making: Selected Proceedings of an Interdisciplinary Research Conference, Rome, 3–6 September, 1973. Theory and Decision Library 1975; 11:141–62. 45 Hall KH. Reviewing intuitive decision-making and uncertainty: the implications for medical education. Med Educ 2002; 36:216–24. 46 Bornstein BH, Emler AC. Rationality in medical decision making: a review of the literature on doctors’ decision-making biases. J Eval Clin Pract 2008; 7:97–107. 47 Russo JE, Schoemaker PJ. Managing overconfidence. Sloan Manage Rev 1992; 33:7–17. 48 Fiore JF Jr, Bialocerkowski A, Browning L et al. Criteria to determine readiness for hospital discharge following colorectal surgery: an international consensus using the Delphi technique. Dis Colon Rectum 2012; 55:416–23. 49 Vreeland DG, Rea RE, Montgomery LL. A review of the literature on heart failure and discharge education. Crit Care Nurs Q 2011; 34:235–45.

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The dermatology outpatient discharge decision: understanding a critical but neglected process.

Discharge from dermatology outpatients is a critical endpoint of patient care. Despite this, there has been very little research concerning the discha...
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