Less Physician Follow-up After Chest-Pain ER Evaluation for the Highest-Risk Patients

Amy Reyes

March 13, 2015

TORONTO, ON — Of patients seen in hospital emergency departments for chest pain and who are released, those with diabetes, cerebrovascular disease, and other chronic disorders received follow-up from their primary-care physician or a cardiologist less often than healthier patients, especially those with "established access to physician care," in a new study conducted in Canada[1].

That followed-up patients tended to lower risk than those not followed up was the single most surprising finding, according to senior author Dr Dennis Ko (Sunnybrook Health Sciences Centre, Toronto, ON) of the study published online in the February 23, 2015 issue of CMAJ, with first author Dr Michael KY Wong (Sunnybrook Health Sciences Centre).

Ko described the apparent inconsistency as a "treatment-risk paradox," in which high-risk patients receive less treatment than healthier patients.

The onus for scheduling a follow-up appointment and keeping that appointment lies with the patient; however, there are factors that influence decisions patients make, and those factors should be addressed by the healthcare system, Ko told heartwire from Medscape. Some patients need more support than others, he said, and unfortunately, those patients are falling between the cracks of complex disconnected healthcare systems.

Dr Rita Redberg (University of California, San Francisco) said in an interview that the observed shortfalls in follow-up by patients are a bigger phenomenon than they would appear. "We need to have a better understanding of why patients who need to come in are not coming in. Is it because they don't have insurance? Is it because life got in the way?"

Redberg, who was not involved in the study, has published extensively on the treatment of patients treated in emergency departments for chest pain. Her studies show that too many tests are ordered and too little follow-up is conducted. In previous studies, she found that less than 1% of patients treated in an emergency department actually have heart disease. Regardless, she emphasized, following up with a primary-care physician is important.

"There is a lot of value in the physician-patient relationship," she said. "The real value is in the follow-up and in having a relationship with your doctor, being able to talk with your doctor about your symptoms and what you can do to be healthier. Maybe patients are coming to the emergency department for treatment because they don't have a primary-care doctor."

The current study is based on a review of medical billing records of 56 767 patients who were seen in a hospital emergency department between April 2004 and March 2010.

Clinical guidelines in Canada recommend that patients who have been treated for chest pain in an emergency department have physician follow-up within 72 hours of discharge. But of the 56 767 patients in the current study, 25.1% of patients did not follow-up with either their primary-care physician or a cardiologist. On the other hand, 17.3% scheduled a follow-up appointment with a cardiologist within 30 days and 69% of patients went to a primary-care physician. Patients who had a history of MI, heart failure, hemiplegia or paraplegia, or dementia were least likely to follow up with a physician.

The researchers focused on predictors that influenced whether a patient followed up with their physician within 30 days of release from a hospital emergency department. Predictors such as access to care, volume of chest pain patients seen at a hospital, and patient characteristics such as age, sex, income, rural residency, and cardiovascular conditions rose to the top of the list.

In an interview with heartwire , Dr Douglas Lee (Toronto General Research Institute, ON) who was not involved in the study, said it clearly shows a gap in the quality of care. "Institutions, emergency departments, and hospitals should look at their own data to get a sense of what their follow-up rates are in their hospitals. If they are at the low end of the spectrum, they should take this opportunity to identify where the gaps in follow-up care are and consider improvements to the quality of care they provide," he said.

Why Don't Patients Follow up With Their Doctor?

Access to care and socioeconomic status were leading predictors. Patients who had an established primary-care physician or cardiologist were more likely to schedule a follow-up appointment. In fact, patients who saw their primary-care physician within the past year had a sixfold increased odds of following up with their physician or a cardiologist after a visit to the emergency department for chest pain (odds ratio [OR] 6.44, 95% CI 5.91–7.01). Likewise, a previous visit to a cardiologist was associated with a threefold increase (OR 3.01, 95% CI 2.85–3.17) of a follow-up visit. Of patients who followed up with a cardiologist, 70.9% were more likely to have seen a cardiologist in the past year or had been admitted to a hospital in the past year.

All of the patients in the study were previously diagnosed with diabetes or a cardiovascular condition, Ko observed, yet only 5.1% of these patients were seen by their primary-care physician in the past year. "We often tell patients to talk to their family doctor and then we send them home, but in reality, they may not have a family doctor."

Ko underscored the importance of ease of access to care. He found that patients treated in the emergency department of a hospital that had an established heart clinic were twice as likely to follow up with a cardiologist. He pointed to the need for development of rapid follow-up clinics, chest-pain clinics, and hospital appointment-booking systems that facilitate connection with the appointment systems of community physicians.

"We believe that a paradigm shift in ensuring follow-up care is needed," the authors write. "It is important to identify and advocate for vulnerable patients for whom follow-up care is less likely."

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