Association between physician follow-up and outcomes of care after chest pain assessment in high-risk patients
Czarnecki A, Chong A, Lee DS, Schull MJ, Tu JV, Lau C, Farkouh ME, Ko DT. Circulation. 2013; 127(13):1386-94.
Background — Assessment of chest pain is one of the most common reasons for emergency department visits in developed countries. Although guidelines recommend primary care physician (PCP) follow-up for patients who are subsequently discharged, little is known about the relationship between physician follow-up and clinical outcomes.
Methods and Results — An observational study was conducted on patients with higher baseline risk, defined as having diabetes mellitus or established cardiovascular disease, who were evaluated for chest pain, discharged, and without adverse clinical outcomes for 30 days in Ontario from 2004 to 2010. Multivariable proportional hazard models were constructed to adjust for potential confounding between physician groups (cardiologist, PCP, or none). Among 56767 included patients, 17% were evaluated by cardiologists, 58% were evaluated by PCPs alone, and 25% had no physician follow-up. The mean age was 66±15 years, and 53% were male. The highest rates of diagnostic testing, medical therapy, and coronary revascularization were seen among patients treated by cardiologists. At 1 year, the rate of death or MI was 5.5% (95% confidence interval, 5.0–5.9) in the cardiology group, 7.7% (95% confidence interval, 7.4–7.9) in the PCP group, and 8.6% (95% confidence interval, 8.2–9.1) in the no-physician group. After adjustment, cardiologist follow-up was associated with significantly lower adjusted hazard ratio of death or MI compared with PCP (hazard ratio, 0.85; 95% confidence interval, 0.78–0.92) and no physician (hazard ratio, 0.79; 95% confidence interval, 0.71–0.88) follow-up.
Conclusions — Among patients with higher baseline cardiovascular risk who were discharged from the emergency department after evaluation for chest pain in Ontario, follow-up with a cardiologist was associated with a decreased risk of all-cause mortality or hospitalization for MI at 1 year compared with follow-up with a PCP or no physician follow-up.
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