Raising the bar for patient experience during care transitions in Canada: A repeated cross-sectional survey evaluating a patient-oriented discharge summary at Ontario hospitals.

BACKGROUND: Patient experience when transitioning home from hospital is an important quality metric linked to improved patient outcomes. We evaluated the impact of a hospital-based care transition intervention, patient-oriented discharge summary (PODS), on patient experience across Ontario acute care hospitals.
METHODS: We used a repeated cross-sectional study design to compare yearly positive (top-box) responses to four questions centered on discharge communication from the Canadian Patient Experience Survey (2016-2020) among three hospital cohorts with various levels of PODS implementation. Generalized Estimating Equations using a binomial likelihood accounting for site level clustering was used to assess continuous linear time trends among cohorts and cohort differences during the post-implementation period. This research had oversight from a public advisory group of patient and caregiver partners from across the province.
RESULTS: 512,288 individual responses were included. Compared to non-implementation hospitals, hospitals with full implementation (>50% discharges) reported higher odds for having discussed the help needed when leaving hospital (OR = 1.18, 95% CI = 1.02-1.37) and having received information in writing about what symptoms to look out for (OR = 1.44, 95% = 1.17-1.78) post-implementation. The linear time trend was also significant when comparing hospitals with full versus no implementation for having received information in writing about what symptoms to look out for (OR = 1.05, 95% CI = 1.01-1.09).
INTERPRETATION: PODS implementation was associated with higher odds of positive patient experience, particularly for questions focused on discharge planning. Further efforts should center on discharge management, specifically: understanding of medications and what to do if worried once home.

Introduction

Improving patient experience following hospital admission is an important target of health systems worldwide [1-3]. Patient experience is a patient-reported measure that allows patients to rank various elements of the hospitalization that were important to them using standardized and validated measures that can be compared across patients, institutions, provinces, countries and drive improvements in quality of care [4]. Patient experience is often also used to complement patient-reported outcome measures to help understand rising numbers of avoidable health-care utilization, yet rarely considered when evaluating the impact of care transition interventions or new models of care [5]. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, designed in the US, is becoming increasingly recognized and used in many parts of the world [6-8] along with the three-item version of the Care Transitions Measure (CTM-3) [9]. In 2014, the Canadian Institute for Health Information (CIHI) created the first Canadian Patient Experience—Inpatient Care (CPES-IC) survey to capture the quality of communication, information sharing and other markers of patient experience for Canadian patients discharged from acute care hospitals [10].

The Patient Oriented-Discharge Summary (PODS) is a novel individualized discharge instruction tool containing five sections of information centered on changes to medications, daily activities and diet, follow-up appointments, symptoms to watch out for and resources [11]. Co-designed with patients and caregivers to improve communication, PODS has been found to increase patient-centered discharge practices by involving family caregivers in discharge conversations and by increasing the use of teach-back, two communication practices known to improve patient outcomes [12, 13]. The objective of this study was to evaluate the association of PODS with patient experience among surgical and medical inpatients across Ontario hospitals.

Methods

Between April 2017 and March 2018, 21 hospitals in Ontario implemented PODS in an inpatient population of their choice through a funded and supported community of practice [13]. The study was reviewed by the University Health Network (UHN) research ethics board. The UHN REB waived ethics approval given the use of aggregate non patient identified data (Waiver 17–5469). Consent was not obtained as the data were analyzed anonymously.

Intervention

PODS contains five sections of written discharge instructions co-designed with patients and family caregivers to be meaningful and usable: 1) medications, 2) changes to daily activities and diet, 3) follow-up appointments, 4) expected and worrisome symptoms to watch for after leaving hospital and 5) resources and contact information. PODS includes design features (large font, pictograms, note-taking section) known to enhance retention and understanding of instructions and is accompanied by process guidelines which foster patient and caregiver engagement and teach-back when reviewing discharge instructions [12]. Prior to PODS implementation, discharge instructions in Ontario hospitals were verbal or a summary directed to the primary care provider [11]. Hospitals who implemented PODS ranged widely in size, geographic area, target patient population, discharge process (i.e., what members of the healthcare team were involved in providing patient education at discharge), whether PODS was implemented in isolation or as part of broader discharge process improvements, and whether the process was supported through the electronic medical record (EMR). There were twenty-three acute care, nine which were considered academic hospitals, eleven large community hospitals and three small community hospitals with under 100 beds [13].

Setting/Patients

Ontario is Canada’s largest province which includes 123 acute care hospitals. The CPES-IC is a standardized and validated survey administered by email, mail or telephone in English or French to adults over 18 years discharged from an Ontario acute care hospital’s medical or surgical unit in the previous 48 hours to three months [14]. Ontario hospitals who collected patient experience data among their medical or surgical inpatients during all four years of the study period, April 2016 to March 2020, were eligible for inclusion in our study. Individuals were only eligible to receive the survey once within the 12-month period following his or her most recent hospital stay.

We received anonymized data to the CPES-IC survey for all hospitals by pre-assigned cohorts. The first cohort included hospitals who implemented PODS among ≥ 50% of medical and surgical inpatients between April 1, 2017 and March 2018. Our second cohort included hospitals who had implemented PODS among <50% of their medical or surgical inpatients in our implementation study by March 2018 or who had some known implementation outside this study. Our third cohort included all other hospitals who collected outcome data but who had no PODS implementation as of December 2018. Further reports on yearly mean age stratified by sex for respondents along with yearly response rate for aggregate questions for discharge planning and management for our study cohort were later obtained from the Canadian Institute for Health Information.

Design

Our study used a repeated cross-sectional design to measure outcomes at four different time points: 1) pre-implementation (April 1, 2016 to March 31, 2017), 2) year 1 of implementation (April 1, 2017 to March 31, 2018), 3) year 2 of implementation (April 1, 2018 to March 31, 2019) and 4) post-implementation (April 1, 2019 to March 31, 2020) in all three cohorts. We used the STROBE cross-sectional checklist when writing our report [15].

Outcomes

We used individual responses to the following four questions from CPES-IC centered on discharge communication as they represented content directly addressed in the PODS intervention. The CPES-IC is based on HCAHPS survey has additional content developed for the Canadian context [10]. Separate responses to the following two questions which reflect discharge planning were used: 1) During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help needed when you left hospital? Responses included no or yes; 2) During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left hospital? Responses included no or yes. Separate responses to the following two questions which reflect discharge management were used: 3) Before you left the hospital, did you have a clear understanding about all your prescribed medications, including those you were taking before your hospital stay? Responses included not at all, partly, quite a bit, completely, not applicable; 4) Did you receive enough information from hospital staff about what to do if you were worried about your condition or treatment after you left the hospital? Responses included not at all, partly, quite a bit, and completely.

Statistical analysis

For each survey question, aggregate percentages of the top box response and 95% confidence intervals for these estimates were computed for each cohort at each time point using Generalized Estimating Equations (GEE), which allowed us to account for site level clustering. The top box response represents the most positive choice for a given individual question and is based on current CIHI CPES and HCAHPS reporting standards in the USA [16]. A second GEE model treated time as a continuous predictor to evaluate linear time trends for each cohort and to assess cohort level differences in the post implementation period. We report all estimates as odds ratios, along with 95% confidence intervals and Wald test p-values. Alpha = .05 is used as the threshold for statistical significance. The use of GEE was felt to be most appropriate to see what, if any, cohort effects exist and rather not meant to conduct a prediction model with random effects and measures of variance for each site and model, respectively. The models were fit using the geepack package in R version 3.6.2.

Results

A total of 512,288 responses aggregated from 59 hospitals were analyzed. Cohort 1 included eight hospitals who implemented PODS fully, cohort 2 included 15 hospitals who implemented PODS partially and cohort 3 included 36 hospitals who had no PODS implementation. The mean age by gender and year for all respondents in Ontario is listed in Table 1. Response rates across Ontario hospitals to the Patient Experience Survey ranged between 28% and 35% (Table 2).

Table 1

Mean age of Ontario patients in CPERS by gender and fiscal year.

	Age
Year	Female		Male
	Mean	Standard deviation	Mean	Standard deviation
Pre-implementation	68	14	60	20
Year 1	68	14	60	20
Year 2	69	13	61	20
Post- implementation	69	14	61	20

aCPERS = Canadian Patient Experience Response Survey

Table 2

Ontario CPES-IC response rates—overall and measures (discharge communication & planning and discharge management) by fiscal year.

		Response Rate
Year	Number of responses	Number of Ontario hospitalsa	Overall	Discharge communication & planningb	Discharge managementc
2016–2017	130,721	61	35.7	33.7	34.6
2017–2018	135,900	68	36.2	33.6	35.1
2018–2019	126,832	84	34.9	32.2	33.8
2019–2020	118,835	96	30.1	27.9	29.1

a n = Number of Ontario hospitals that submitted data to CPERS

b The measure Discharge Planning consists of CPES-IC questions 19 (help needed after leaving hospital) and 20 (information in writing about symptoms to look out for)

c The measure Discharge Management consists of CPES-IC questions 37 (understanding about medications) and 38 (what to do if worried after leaving hospital) along with an additional question not included in our survey, question 39 (better understanding of condition post discharge).

Individuals discharged from hospitals with no PODS implementation had lower pre-implementation patient experience scores for all questions when compared to individuals discharged from hospitals with PODS implementation (Fig 1). The odds of reporting a positive patient experience in the post implementation period was statistically higher for two of four questions when compared to non-implementing hospitals (Table 3). Specifically, the odds of a positive response for having discussions with hospital staff on help needed and receiving information in writing about what symptoms to look for after leaving hospital was higher among hospitals with full implementation (cohort 1) when compared to those with no implementation (cohort 3). The odds of receiving information in writing about what symptoms to look for was also higher among partially implementing hospitals (cohort 2) when compared to those with no implementation (cohort 3). However, there was a statistically significant linear time trend difference between hospitals with full implementation (cohort 1) versus no implementation (cohort 3) for receiving information in writing about what symptoms to look for after leaving hospital and between hospitals with some implementation (cohort 2) versus no implementation (cohort 3) for having discussions with hospital staff on help needed (Table 3). Visual representations of the full model adjusting for time and clustering of sites with variability in the speed of each hospitals’ individual response are displayed in S1 Fig.

Fig 1

Percentages of positive patient experience by cohort over time, accounting for site level clustering, using GEE.

Table 3

Odds of a positive patient experience following discharge from acute care hospital one year following PODS implementation when compared to hospitals with no intervention.

	Full PODS implementation		Partial PODS implementation
Question	Odds ratio (95% CI)	p-value	Odds Ratio (95% CI)	p-value
Help needed after leaving hospital	1.18 (1.02–1.37)	0.025	1.05 (0.92–1.20)	0.488
Information in writing about symptoms to look out for	1.44 (1.17–1.78)	<0.001	1.35 (1.04–1.76)	0.023
Clear understanding about medications	0.96 (0.86–1.08)	0.517	0.99 (0.89–1.10)	0.858
Information about what to do if worried after leaving hospital	1.08 (0.90–1.29)	0.414	1.06 (0.91–1.22)	0.473
Linear Time Trend (slope)
Help needed after leaving hospital	1.02 (0.98–1.06)	0.440	0.97 (0.94–0.99)	0.021
Information in writing about symptoms to look out for	1.05 (1.01–1.09)	0.027	0.96 (0.91–1.02)	0.209
Clear understanding about medications	0.98 (0.93–1.02)	0.308	0.99 (0.95–1.02)	0.507
Information about what to do if worried after leaving hospital	0.98 (0.92–1.04)	0.480	0.99 (0.94–1.05)	0.817

Note: There was a significant association between time and the outcome for cohort 3 for each outcome for the reference group (cohort 3) for all questions.

Discussion

Our study found the delivery of a discharge instruction tool was associated with an improvement in patient experience for hospitals who implemented PODS, particularly for both questions related to discharge planning. These are promising results given the recent attention of both patients and Ontario Health, the province’s integrated health system planning and oversight agency, has given to improving quality standards in care transitions [17-19]. PODS however was not associated with an improvement to questions related to discharge management, such as understanding medications or what to do if worried after discharge, though linear time trends demonstrate active efforts in the province may be having a positive impact beyond the effect demonstrated by our tool. Our study highlights both where current care transition efforts are having the greatest impact and where gaps may still remain to improve patient experience.

Improving patient experience during care transitions from hospital to home has gained much attention over the last 10 years [4-9]. However, Canada has only focused on capturing patient experience recently [10, 14, 18–21]. Our study provides a deeper dive into areas for system improvement at a time when care coordination and communication practices were likely further hindered due to the COVID-19 pandemic [22, 23]. Previous studies have demonstrated the role between high quality care transitions and post-discharge outcomes [1, 3, 9, 12, 24]. Interestingly, our study demonstrates higher patient experience scores than was reported in the only other cross-sectional study of patient experience across multiple Canadian provinces [21]. While some differences may be due to our focus on discharge management rather than patient satisfaction which was included in this study, our results likely represent the increasing attention on care transition quality and hospital-specific initiatives that are underway in Ontario [17]. The positive linear time trend reported in our non-implementing cohort is a reflection of these efforts. Our study strengthens prior work by providing repetitive cross-sectional measurement of patient experience over time allowing the identification of persistent gaps in patient experience across the largest Canadian province. Our study found a poor receipt of information on what to do if problems arise following hospitalization with just under 60% reporting positive scores. This finding may identify persistent gaps in this particular area but may also be a reflection of challenges in care coordination and health systems’ access patients’ and families’ have voiced they face once home [18].

While many interventions aim to help address poor post-discharge outcomes stemming from poor communication such as self-care behaviors or emergency department visits and readmissions [1-3], few have evaluated the impact on patient experience [25-28]. Our paper is one of the first to use Canadian patient experience measures to evaluate its association with the widespread implementation of a novel discharge communication tool. Our study is comparable to US studies which have studied the impact of care interventions on patient experience using identical or similar questions [27, 28]. Patients randomized to receive a tailored discharge care plan along with one-on-one discussions with a health care provider on symptom recognition, medication reconciliation, and strategies for navigating the health system along with care coordination when needed were not found to have improved patient experience [27]. It is also possible that the impact of these care interventions lays more in the fidelity of the tool however–such as a higher engagement of caregivers or use of teach-back [13]. This may help explain why patients discharged from hospitals implementing PODS had a higher odds of having discussed the help they would need once leaving hospital, given patients may rely on caregivers for tasks beyond what public home care provides.

PODS was not found to improve patient experience measures related to discharge management. First, PODS was not found to improve the odds of reporting understanding of medications. In order to allow PODS to be usable across a wide range of patient populations and care systems, medication instructions were not standardized. Moreover, other province-wide care models centered on medication instructions were underway at the time of PODS implementation across Canada. Second, PODS was not found to improve understanding of what to do if problems arise after discharge from hospital. As a written form used prior to discharge to document instructions, PODS may do a better job of highlighting signs and symptoms patients and their families should watch out after leaving hospital, rather than where to seek care when complications arise. Prior studies have shown that seeking care when complications arise is influenced by system issues such as access to and relationships to primary care or specialist follow-ups, access issues which were unmeasured in our study [29, 30]. Lastly, as PODS implementation did not include post-discharge reinforcements, care coordination or follow-up, this may help explain why questions centered on discharge management were not associated with implementation of our tool, unlike other care interventions [1].

Our study has several limitations. First, our study used hospital aggregate data, not individual patient data, and we cannot make causal inferences on the individual impact of receiving PODS on patient experience. While it is possible that individuals left a fully or partially implementing hospital with no PODS, this would make the likelihood of seeing an association less likely–and may have contributed in the partially implementing cohort. Second, the response rate for the survey is low across participating hospitals, with some hospitals having lower responses for certain time periods, and our results may not be representative of patient experience at all Ontario hospitals. This may be offset however by the wide representation of responses across both medical and surgical units and the similar low response rate in all cohorts which is consistent with response rates reported for this nationally used survey [10, 21]. Future patient-level studies would benefit from a nonresponse adjustment being applied. Though the likelihood that hospitals with the most interest in improving their patient experience were involved is high and may help explain why our study reported overall higher patient experience scores in all cohorts than reported previously [21]. Moreover, our study did not include a measure of overall satisfaction, which may be an important measure to evaluate how overall experience may have varied over time. As the entire CPES-IC survey was not used in our study, it is possible we did not capture all aspects of care transition quality, and further research would be strengthened by the inclusion of patient-reported outcome measures. However, at minimum, we feel the chosen questions do reflect content areas in PODS and gaps in communication which have been identified in need of improvement [11, 17, 20].

Our study demonstrated an improvement to patient experience measures that center on discharge planning among individuals discharged home from Ontario medical and surgical units who implemented PODS. Our study highlights that while PODS is a promising discharge instruction tool, further refinement may be necessary in particular in areas which center on discharge management. Further research would benefit by including patient experience measures when evaluating new models of care or care interventions.

Reporting checklist for cross sectional study.

(DOCX)

Click here for additional data file.

GEE model fits with site level data.

(DOCX)

Click here for additional data file.

7 Jul 2022

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Kuo-Cherh Huang

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match.

When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section.

3. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

"Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access.

We will update your Data Availability statement to reflect the information you provide in your cover letter.

Additional Editor Comments:

Dear Dr. Okrainec,

We appreciate your submission to PLOS ONE. Although your paper is interesting, both reviewers have provided a variety of important concerns, notably the data analysis part and other issues within the Methods of your study. Please respond to each comment of the reviewers carefully and thoroughly. Please explain where you feel you cannot completely agree with reviewers’ suggestions. Additionally, on the title page, there is such a declaration: “¶These authors contributed equally to this work.” Accordingly, all eight authors of this manuscript are the first author (and the corresponding author as well since the first author was designated as the corresponding author), then? It seems pretty odd to me because the manner of authorship is patently against the guidelines set by the International Committee of Medical Journal Editors (ICMJE), which had established a list of recommendations to elucidate the definition and responsibilities of an author (http://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html).

Kuo-Cherh Huang

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review this well-written paper which examined the association between a patient-oriented discharge summary (PODS) and measures of patient experience across hospitals in Ontario. I enjoyed reading the paper.

My specific comments and minor and are as follows:

On line 2 of the introduction, please remove the second instance of “experience”.

In the methods section, please mention that the CPES-IC was based on the HCAHPS survey from the US, with additional content developed for the Canadian context. Reference number 10 may be used to support this.

Was there a measure of PODS completeness once implemented at each site? Also, please describe more details about the hospitals which were included in this study (e.g. urban vs. rural, teaching/non-teaching, bed size, etc.).

During the intervention, who was responsible for administering the PODS? Was if the physician or a nurse on the ward?

If possible, could you please report on the overall experience during the study? Although discharge planning has not been shown to have high correlation with overall experience on the HCAHPS or CPES-IC, it may be important to show how overall experience may have varied (if any) over the study period.

In the statistical analysis section, please provide a description for “top response” for readers who may not be familiar.

Thank you for including patient partners within your research team.

In the results section, 59 hospitals were included, but the sum of the three cohorts is 60 hospitals. Please clarify.

The results, discussion, and tables are well-presented. In each regression analysis, however, it may be worthwhile to present a measure of how much of the variance was explained by the model.

Were you able to examine the percentage of unplanned readmissions at each hospital over the study period? This data would also be available from CIHI and may highlight the benefit of using the PODS at a hospital or system-level.

On a personal note, on the day of my review, I was saddened to learn of the passing of Dr. Krahn. Please accept my sincere condolences.

Reviewer #2: This study adopted a repeated cross-sectional study design (also known as a pseudo-longitudinal design) to assess the impact of a hospital-based care transition intervention (patient-oriented discharge summary; PODS) on patient experience across Ontario acute care hospitals four waves. The authors concluded that the PODS implementation of PODS was associated with higher odds of positive patient experience, particularly with regard to discharge planning. There are several grave issues that should be addressed to further improve on this work, as the attached comments indicate.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Kyle Kemp

Reviewer #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: Comments.docx

Click here for additional data file.

1 Sep 2022

September 1, 2022

Dear Kuo-Cherh Huang:

Thank you to the reviewers and editorial team for your comments on our manuscript, “Raising the bar for patient experience during care transitions in Canada: A repeated cross-sectional survey evaluating a patient-oriented discharge summary at Ontario hospitals.”

Below are itemized responses to the list of feedback you provided for our manuscript.

We have reviewed our manuscript to ensure it meets PLOS ONE’s style requirements.

We have ensured the grant numbers (when applicable – awards are not assigned numbers) are correct in the Funding Information and ensured the information is the same in the Financial Disclosure and Funding Information sections. We have removed any funding-related text from the manuscript.

Additionally, on the title page, there is such a declaration: “¶These authors contributed equally to this work.”

We thank the editor for picking up this error. There is only one corresponding author, and authors’ contributions’ have been clarified in the online submission program, as described in ICMJE guidelines. We have revised our title page to be in line with requirements and appropriate language of PLOS ONE and have removed the symbols.

Reviewers' comments:

Reviewer #1:

On line 2 of the introduction, please remove the second instance of “experience”.

We have removed the second instance of experience on line 2 of the introduction.

In the methods section, please mention that the CPES-IC was based on the HCAHPS survey from the US, with additional content developed for the Canadian context. Reference number 10 may be used to support this.

We thank the reviewer for this suggestion and have added this additional information on Pages 5-6 in the methods section to complement what is already included in the introduction section.

Was there a measure of PODS completeness once implemented at each site? Also, please describe more details about the hospitals which were included in this study (e.g. urban vs. rural, teaching/non-teaching, bed size, etc.). During the intervention, who was responsible for administering the PODS? Was if the physician or a nurse on the ward?

We thank the reviewer for asking these excellent questions which relate to implementing hospitals (both full and partial hospitals) which make up 39% of our study sample. We have provided more information on the intervention on page 4 along with information on the hospitals included.

If possible, could you please report on the overall experience during the study? Although discharge planning has not been shown to have high correlation with overall experience on the HCAHPS or CPES-IC, it may be important to show how overall experience may have varied (if any) over the study period.

While we agree that additional survey questions related to overall experience may have been helpful to include, these questions were not requested by our third party and are beyond the scope of this project. We have added this to our limitations on page 13, as while the literature is absent in this area, it could be explored in further studies.

In the statistical analysis section, please provide a description for “top response” for readers who may not be familiar.

We have added a description of top box in the methods section on page 6.

In the results section, 59 hospitals were included, but the sum of the three cohorts is 60 hospitals. Please clarify.

Thank you for picking up this error. We have clarified that 59 hospitals were included and corrected a typo within one of the cohorts’ totals.

The results, discussion, and tables are well-presented. In each regression analysis, however, it may be worthwhile to present a measure of how much of the variance was explained by the model.

With the use of GEE, we are accounting for clustering when we compute the confidence intervals for the parameters in the models, but the model does not “fit” the sites in the same way and a pseudo R2 (measure of variance) would more typically and be more appropriate for a generalized linear mixed effects model where we would have modeled the site level with random effects. As our objective was not to conduct a prediction model, and rather to see what, if any, cohort effects exist, we feel that adding a measure of variance (for fit) will not be helpful. We have clarified the use of GEE and its purpose in our methods on page 6. If the reviewers or editor feel strongly however and would like us to include a pseudo R2, we can add a pseudo R2 for the entire model (which contains all 3 cohorts) for the 4 questions but with an additional sentence on the limitations in how the R2 is interpreted using GEE.

Were you able to examine the percentage of unplanned readmissions at each hospital over the study period? This data would also be available from CIHI and may highlight the benefit of using the PODS at a hospital or system-level.

This is an excellent suggestion which is the focus of the last part of our multiphase analysis for our PODS intervention (currently underway at ICES), but beyond the scope of this report.

On a personal note, on the day of my review, I was saddened to learn of the passing of Dr. Krahn. Please accept my sincere condolences.

Thank you.

Reviewer #2:

In the main text the declared inferential statistical method was GEE (p. 6). Nonetheless, in the abstract it was logistic regression analysis. This is a palpable oversight.

Thank you for picking up this mistake which we have revised in our abstract.

With respect to the outcome measures, for the first outcome variable of discharge planning there were two questionnaire items with binary responses (yes and no). As for the other outcome measure (discharge management), the authors employed Likert-type 5-point scale for the first question and 4-point scale for the other question. I am left wondering after reading this piece of text -- how did the authors come up with a single value to indicating “a positive patient experience”?

Thank you for the excellent questions. We have clarified throughout the manuscript (e.g., pages 2, 6 and page 10) that we use the top box response to define a positive experience for all 4 questions individually for our analysis, which is based on current CIHI CPES and HCAHPS reporting standards in Canada and the USA and provided references. We have further clarified that discharge management and discharge planning are only categories for which 2 of the questions fall under, rather than a unique aggregate analysis.

Following on from the above point, I then realized that indeed the authors had analyzed each relevant question separately when I reached Table 3 (starting from the bottom of p. 8). I do not think that this is an appropriate analytical method -- in this study the two outcome variables were discharge planning and discharge management. Questionnaire items are not the same as variables. Stated differently, the former is employed to measure the existence or degree of the latter. Indeed, the focus of the authors’ related discussion of analytical results was on the two outcome variables, not each of the four questionnaire items; for example, in the abstract, “Interpretation: [sic] PODS implementation was associated with higher odds of positive patient experience, particularly for discharge planning [emphasis added]. Further efforts should center on discharge management [emphasis added]”.

Please see response to question above where we clarify that discharge planning and management are two of several categories which were used to address several areas of patient experience, but are not unique outcomes variables.

P. 6, Involvement of Patient Partners. I do not think the information under this subsection essential at all in the main text. In addition, it is peculiar to present such information after the descriptions of statistical analysis.

We have removed the involvement of patient partners category in the main text and main reference to our patient partners in the acknowledgment section.

Abstract, Results, “512,288 responses were included with mean age 69 ± 14 years (females) and 61 ± 20 years (males).” The authors only presented descriptive statistics as regards the mean ages of both genders, but no information concerning the gender composition of sample patients. Furthermore, although it is not a panel study design, would it be possible that “512,288 responses” included a number of same patients? If yes, then the mean age statistics may not be accurate.

We have removed the line which refers to age in our abstract as the reviewer is correct that only descriptive statistics of the mean ages of both genders by year were available from the third party (CIHI) which supplied the aggregate data. This survey is sent out to a random sample of individuals discharged from the medical and surgical units of hospitals in Ontario. It can only be sent to the same individual every 12 months and so repeated measurements from the same patient are unlikely. This has been clarified on page 5 of the methods section.

Relatedly, with regard to Table 1 on page 7 -- why did the authors kind of emphasize age statistics (and age only) as to have a table solely for the results?

As stated above, only descriptive statistics of the mean ages of both genders by year were available from the third party (CIHI) which supplied the aggregate data.

We hope you agree that with our revisions, our manuscript has been strengthened and will consider it for publication.

Sincerely,

Karen Okrainec (on behalf of all authors)

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

19 Sep 2022

Raising the bar for patient experience during care transitions in Canada: A repeated cross-sectional survey evaluating a patient-oriented discharge summary at Ontario hospitals

PONE-D-22-12504R1

Dear Dr. Okrainec,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Kuo-Cherh Huang

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review this revised manuscript. I thank the authors for taking the time to address the comments raised during my initial review. I have no additional comments at this time.

Reviewer #2: The authors have been responsive to my prior comments in a point-by-point fashion, and their responses are satisfactory; much appreciated. I do not have any further inquiry with the paper.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Kyle Kemp

Reviewer #2: No

**********

26 Sep 2022

PONE-D-22-12504R1

Raising the bar for patient experience during care transitions in Canada: A repeated cross-sectional survey evaluating a patient-oriented discharge summary at Ontario hospitals

Dear Dr. Okrainec:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Kuo-Cherh Huang

Academic Editor

PLOS ONE