Effect of early physician follow-up on mortality and subsequent hospital admissions after emergency care for heart failure: a retrospective cohort study
Atzema CL, Austin PC, Yu B, Schull MJ, Jackevicius CA, Ivers NM, Rochon PA, Lee DS. CMAJ. 2018; 190(50):1468-77. Epub 2018 Dec 17.
Background — The 1-year mortality rate in patients with heart failure who are discharged from an emergency department is 20%. We sought to determine whether early follow-up after discharge from the emergency department was associated with decreased mortality or subsequent admission to hospital.
Methods — This retrospective cohort study conducted in Ontario, Canada, included adult patients who were discharged from 1 of 163 emergency departments between April 2007 and March 2014 with a primary diagnosis of heart failure. Using a propensity score–matched landmark analysis, we assessed follow-up in relation to mortality and admissions to hospital for cardiovascular conditions.
Results — Of 34 519 patients, 16 274 (47.1%) obtained follow-up care within 7 days and 28 846 (83.6%) within 30 days. Compared with follow-up between day 8 and 30, patients with follow-up care within 7 days had a lower rate of mortality over 1 year (hazard ratio [HR] 0.92; 95% confidence interval [CI] 0.87–0.97), and a reduced rate of admission to hospital over 90 days (HR 0.87, 95% CI 0.80–0.94) and 1 year (HR 0.92; 95% CI 0.87–0.97); the mortality rate over 90 days in this group trended to a lower rate (HR 0.90, 95% CI 0.10–1.00). Follow-up care within 30 days, compared with patients without 30-day follow-up, was associated with a reduction in 1-year mortality (HR 0.89, 95% CI 0.82–0.97) but not admission to hospital (HR 1.02, 95% CI 0.94–1.10). In this group, there was a trend toward an increase in 90-day admission to hospital (HR 1.14, 95% CI 1.00–1.29).
Interpretation — Follow-up care within 7 days of discharge from the emergency department was associated with lower rates of long-term mortality, as well as subsequent hospital admissions, and a trend to lower short-term mortality rates. Timely access to longitudinal care for patients with heart failure who are discharged from the emergency setting should be prioritized.
Patients with heart failure often experience exacerbations of their disease, when they may seek care in an emergency department. There are over a million visits to the emergency department for heart failure annually in North America, accounting for 3% of all visits, and they are increasing. Between 64% and 84% of these patients are admitted to hospital in Canada, Europe and the United States. In Canada, the direct costs of heart failure are $2.8 billion per year. Admissions to hospital constitute most of the expenditures on heart failure and in the current environment of accelerating health care costs, there is growing preference to choose outpatient over inpatient management where possible. However, there are limited data on the effect and timing of follow-up care on outcomes after discharge from an emergency department. Physician follow-up within 7 days of discharge from the hospital has been associated with lower 30-day readmissions in patients with heart failure.
In the emergency department, acute symptoms of heart failure are usually treated with diuretics. However, it is long-term disease management, including administration of guideline-directed medical therapy, that likely decreases the risk of death and subsequent admissions to hospital. Follow-up care is needed to ensure that guideline-directed medical therapy is instituted and dosages are optimized, and that early evidence of deterioration is addressed. Emergency physicians recommend follow-up for cardiovascular ambulatory care sensitive conditions within 7 days, but the optimal timing of physician follow-up is unclear. We sought to determine what the optimal timing of physician follow-up should be by examining the association between timing of follow-up care and subsequent admissions to hospital and death.
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