Physicians' Academy for Cardiovascular Education

Physician continuity improves outcomes of HF patients after treatment and release from ED

Literature - Sidhu RS et al., JACC Heart Fail. 2014 - JACC Heart Fail. 2014 Jul 2. doi: 10.1016/j.jchf.2014.03.006. [Epub ahead of print]

 

Physician Continuity Improves Outcomes for Heart Failure Patients Treated and Released From the Emergency Department

 
Sidhu RS, Youngson E, McAlister FA
JACC Heart Fail. 2014 Jul 2. doi: 10.1016/j.jchf.2014.03.006. [Epub ahead of print]
 

Background

About 25% to 35% of patients with heart failure (HF) who present to the emergency department (ED), are discharged directly from the ED [1,2]. Little is known about outcomes of these ‘treated and released’ patients, although one study showed that mortality and hospitalisation rates in these patients are as bad as those for patients admitted to the hospital [2]. Another study even showed that released patients had worse 30-day outcomes than admitted patients [1].
Early outpatient follow-up is associated with better outcomes for HF patients discharged from the hospital [3,4], as well as for treated and released patients [5]. Specifically post-discharge follow-up with a physician familiar with the patient results in lower rates of mortality and/or rehospitalisation [4,6-8]. The benefits of physician continuity in HF patients treated and released directly from ED are less clear.
This study therefore examined whether outcomes differed for HF patients treated and released from the ED if they followed up with physicians who knew them, as compared with follow-up with a physician unfamiliar with their case. Over a period of 10 years, 12.285 (36.6%) of the 33.589 adults with a first-time diagnosis of HF assessed in an ED were treated and released.
 

Main results

  • Of the patients who were treated and released, 2531 (20.6%) patients did not see a physician for follow-up within 30 days of discharge.
  • 11.6% of patients saw only unfamiliar physicians for follow-up, while a majority (67.9%) of patients had at least 1 visit with a familiar physician in the 30 days after ED discharge. Patients receiving familiar physician follow-up had more comorbidities than those receiving unfamiliar follow-up.
  • At 30 days post-ED release, more patients without a follow-up visit had died or were admitted to the hospital (25.4%, n=643), than those followed up by an unfamiliar physician (21.6%, n=303), or a familiar physician (17.1%, n=1428). Repeat ED visits in that month were also lower for patients receiving familiar follow-up.
  • Follow-up with a familiar physician in the first 30 days post-ED release was associated with a lower risk of death or hospitalisation at 3, 6, and 12 months, as compared with no or unfamiliar follow-up. Exclusion of patients who returned to their long-term care facility or patients who were admitted to the hospital within 2 days after the ED visit, did not change the association.
  • Unfamiliar follow-up was not associated with a lower risk of death or hospitalisation as compared with no outpatient follow-up.
  • Any degree of familiar follow-up was associated with significantly lower risks of death or hospitalisation compared with unfamiliar follow-up (adjHR: 0.79, 95%CI: 0.71-0.89 at 3 months, adjHR: 0.86, 95%CI: 0.77-0.95 at 6 months, adjHR: 0.87, 95%CI: 0.80-0.96 at 12 months).
 

Conclusion

The majority of patients in Alberta, Canada, who were treated and released from the ED with a diagnosis of HF were seen in an outpatient clinic within 30 days of ED discharge, and over two-thirds of these patients were followed up by a physician who had previously seen them. Follow-up with a familiar physician was associated with a statistically significantly lower risk of death or hospitalisation. This effect was already evident in the first month, but persisted over the observation period of a year after the ED visit. Thus, physician continuity is beneficial for HF patients discharged from the hospital. Outcomes may be optimised if follow-up with a familiar physician is facilitated, rather than arranging follow-up at an urgent access clinic where the patient would see a new physician.

 
Editorial comment [9]

“These are interesting and important findings, but determining the mechanism underlying these relationships is equally important as we, as members of a research and clinical community, try to determine how this report should change practice. 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?
It will be important to replicate these findings in other countries and other care settings as we try to tease apart the degree to which the authors’ findings are related to systems versus patient factors.
It is one of the particular joys of outpatient medicine to see a familiar face in the office; this study suggests that it may also be of significant benefit to the patient in terms of hard medical outcomes.”
 
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References

1. Lee DS, Schull MJ, Alter DA, et al. Early deaths in patients with heart failure discharged from the emergency department: a population-based analysis. Circ Heart Fail 2010;3:228–35.
2. Brar S, McAlister FA, Youngson E, et al. Do outcomes for patients with heart failure vary by emergency department volume? Circ Heart Fail 2013;6:1147–54.
3. Hernandez AF, Greiner MA, Fonarow GC, et al. Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA 2010; 303:1716–22.
4. McAlister FA, Youngson E, Bakal JA, et al. Impact of physician continuity on death or urgent readmission after discharge among patients with heart failure. CMAJ 2013;185:e681–9.
5. Lee DS, Stukel TA, Austin PC, et al. Improved outcomes with early collaborative care of ambulatory heart failure patients discharged from the emergency department. Circulation 2010;122:1806–14.
6. Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med 2011;155:152–9.
7. Van Walraven C, Taljaard M, Etchells E, et al. The independent association of provider and information continuity on outcomes after hospital discharge: implications for hospitalists. J Hosp Med 2010;5:398–405.
8. Van Walraven C, Oake N, Jennings A, et al. The association between continuity of care and outcomes: a systematic and critical review. J Eval Clin Prac 2010;16:947–56.
9. Joynt KE. So nice to see you again. Physician continuity and outcomes for heart failure. JACC: Heart Failure. 2014; 2: 4. http://dx.doi.org/10.1016/j.jchf.2014.04.003

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