Appropriate and inappropriate influences on outpatient discharge decision making in dermatology: a prospective qualitative study

Summary Background Outpatient discharge decision making in dermatology is poorly understood. Objective To identify the influences on clinicians' thought processes when making discharge decisions in dermatology outpatient clinics. Methods Forty clinicians from 11 National Health Service Trusts in England were interviewed. The interviews were audiorecorded, transcribed, coded and thematically analysed. Results The mean age of the clinicians was 48·8 years (range 33·0–67·0), 17 (43%) were men and 19 (48%) had > 20 years of clinical experience. One hundred and forty‐eight influences were reported, with five main themes: (i) disease‐based influences included type of diagnosis (100% of clinicians), guidelines (100%) and treatment needed (100%); (ii) clinician‐based influences included the clinician's level of experience (100%), seniority (37%), emotional attitude (95%), ‘gut feeling’ (25%), personal attitude towards discharge (45%) and level of perception (100%); (iii) patient‐based influences included patients' ability to cope with their disease (100%), wishes (70%), quality of life (32%), command of English (40%) and cultural background (25%); (iv) practice‐based influences included good primary care (100%), secondary support structure (100%) and clinic capacity pressure (67%); (v) policy‐based influences included pressure from hospital managers (57%) and an active discharge policy (7%). Fourteen (9%) influences were potentially inappropriate. Conclusion This study has identified multiple factors influencing outpatient discharge decision making. This provides the basis for developing evidence‐based training to improve discharge decision appropriateness. What's already known about this topic? The process of discharging an outpatient is critical to organizing an efficient service. Both clinical and nonclinical factors influence outpatient discharge decision making. What does this study add? There is a huge range of influences on clinicians during the process of discharging patients from outpatient clinics. Most influences are appropriate but some may be inappropriate. There is a need to train clinicians in how to make appropriate outpatient discharge decisions.