Physician continuity, early follow-up improved outcomes after ED visit for HF

Early follow-up, particularly when conducted by a physician familiar to the patient, was associated with better outcomes among patients with HF treated and released from the ED in a recent retrospective cohort study.

Researchers evaluated 12,285 patients (mean age, 74.9 years) who were treated at and discharged from 93 EDs throughout Alberta, Canada, with a first-time diagnosis of HF between 1999 and June 30, 2009. Patients were categorized as having undergone no follow-up visits (20.6% of patients), at least one follow-up visit with a familiar physician (67.9%) or having undergone follow-up visits only with unfamiliar physicians (11.6%) within 30 days of discharge. “Familiar physicians” were defined as doctors who had seen the patient at least twice in the year before or during the index ED visit. The primary outcome was death or urgent rehospitalization within 6 months of the index ED visit.

Patients with no outpatient follow-up visits had a mortality or all-cause hospitalization rate of 58.1% at 6 months. This rate was lower among patients who had an outpatient visit with a familiar physician within a month of discharge (37.3%; adjusted HR=0.89; 95% CI, 0.83-0.96), as well as among those who had outpatient visits within 1 month, but only with unfamiliar physicians (40.2%; adjusted HR=1.04; 95% CI, 0.94-1.15).

After excluding patients with no follow-up, the researchers observed a lower risk for death or hospitalization among patients whose follow-up during the study period included a familiar physician compared with those who only underwent follow-up with unfamiliar physicians (adjusted HR=0.79; 95% CI, 0.71-0.89 at 3 months; adjusted HR=0.86; 95% CI, 0.77-0.95 at 6 months; and adjusted HR=0.87; 95% CI, 0.8-0.96 at 12 months). The researchers also noted that receiving any follow-up within 30 days of ED discharge was correlated with a reduced risk for a repeat ED visit or death at 6 months, both with a familiar physician (adjusted HR=0.78; 95% CI, 0.73-0.82) and with unfamiliar physicians (adjusted HR=0.79; 95% CI, 0.72-0.86).

“Our findings present clear evidence for physicians and policymakers to guarantee that systems are in place to ensure prompt follow-up to HF patients after an ED visit,” the researchers concluded. “… Physicians should strive to optimize continuity with HF patients after ED release, and health care systems should introduce strategies to ensure early outpatient follow-up with the patients’ regular physician or a physician who had seen them in the ED.”

Karen E. Joynt

In a related editorial, Karen E. Joynt, MD, MPH, of Brigham and Women’s Hospital, wrote that these findings raise important questions regarding the nature of the relationship between physician follow-up and patient outcomes.

“The crux of the matter is the following: Are patients who see a familiar physician better off simply because of the familiarity, or is there something different about patients who see a familiar physician compared with patients who do not?” Joynt wrote. “The former suggests that a guideline or policy change should be made to encourage early follow-up with a familiar physician; the latter suggests that there may be a group of patients who are inadequately plugged in to the system who may need extra attention.”

For more information:

Joynt KE. JCHF. 2014;doi:10.1016/j.jchf.2014.04.003.

Sidhu RS. JCHF. 2014;doi:10.1016/j.jchf.2014.03.006.

Disclosure: The researchers report no relevant financial disclosures.