Understanding clinician influences and patient perspectives on outpatient discharge decisions : A qualitative study

Objective: To observe the influences on clinicians when discharging patients, to explore patients' perspectives concerning their discharge or follow-up decision and to identify what patients think is important for clinicians to consider when taking a discharge decision. Design: Qualitative study involving observations of consultations and semistructured interviews with outpatients. Setting: National Health Service outpatient clinics at a university hospital secondary referral centre. Participants: 64 consultations were observed followed by 56 interviews with patients aged over 18 years. Main outcome measure: Analysis of patients' perspectives and expectations concerning whether or not they were discharged. Results: 25 types of influences were observed to be influencing the discharge decision process. All 31 discharged patients appeared to accept the clinicians' decision; however, 10 (22%) of those patients later expressed disappointment. Patients' discontent was due to perceived clinicians' uncertainty in diagnosis (patients mentioning=2), poor acceptance of the diagnosis (2), disease not 'cured' (4), differing perception on medical needs (2), lack of concern for job demands (1), felt uninvolved in the decisionmaking (4), feeling rushed (3), prolonged open appointment (2), pushed to seek private care due to healthcare budget constraints (2), language barrier (1) and not keen to continue follow-up with general practitioner (2). Patients were happy when there was certainty of the diagnosis (19), clear treatment plan (16), advised on treatment side effects (7), given a contact number if symptoms recurred (4), considering their travelling and job demands (3). Conclusions: This study highlights the importance of accurately perceiving patients' perspectives in ensuring the appropriateness of outpatient discharge. There was a disparity between patients' and clinicians' perception on what was an appropriate discharge. This included discrepancies concerning diagnostic certainties, private healthcare as an alternative, need for easy reaccess and choice of words surrounding discharge. Medical education should include handling these issues.