Factors associated with physician follow-up among patients with chest pain discharged from the emergency department

Abstract

Background: Many patients with chest pain do not receive follow-up from a physician after discharge from the emergency department despite significant survival benefit associated with follow-up care. Our objective was to evaluate factors associated with physician follow-up to understand this gap in practice.

Methods: We conducted an observational study involving patients at high risk who were assessed for chest pain and discharged from an emergency department in Ontario between April 2004 and March 2010. We used multivariable logistic regression to determine the association of clinical and nonclinical characteristics with physician follow-up.

Results: We identified 56 767 patients, of whom 25.1% did not receive any follow-up by a physician, 69.0% were seen by their primary care physician, and 17.3% were seen by a cardiologist within 30 days. Patients who had medical comorbidities and cardiac conditions such as myocardial infarction or heart failure were less likely to have follow-up. In contrast, a previous visit to a primary care physician was associated with the highest odds of having physician follow-up (odds ratio [OR] 6.44, 95% confidence interval [CI] 5.91-7.01). Similarly, a previous visit to a cardiologist was strongly associated with follow-up by a cardiologist (OR 3.01, 95% CI 2.85-3.17). Patients evaluated in emergency departments with the highest tertile of chest pain volume were more likely to receive follow-up from any physician (OR 1.52, 95% CI 1.31-1.77) and from a cardiologist (OR 2.04, 95% CI 1.61-2.57).

Interpretation: Nonclinical factors are strongly associated with physician follow-up for patients with chest pain after discharge from the emergency department. However, patients with comorbidities and at higher risk for future adverse events are less likely to receive follow-up care.

© 2015 Canadian Medical Association or its licensors.

Figures

Figure 1:

Time course of physician follow-up after discharge from emergency department. The cumulative percentage of patients who received follow-up within 30 days of discharge from the emergency department is shown by physician type.

Figure 2:

Adjusted odds of physician follow-up within 30 days for adult patients with established cardiovascular disease or diabetes who underwent assessment for chest pain and were discharged from the emergency department during the study period. Baseline demographics, cardiac risk factors and medical conditions, events in the emergency department, use of health services in the previous year and hospital characteristics were included in the model. CI = confidence interval. Note: Reference standards presented in Table 1.

Figure 3:

Odds of cardiology follow-up within 30 days for adult patients with established cardiovascular disease or diabetes who underwent assessment for chest pain and were discharged from the emergency department during the study period. Baseline demographics, cardiac risk factors and medical conditions, events in the emergency department, use of health services in the previous year and hospital characteristics were included in the model. CI = confidence interval. Note: Reference standards are presented in Table 2.