CJEM Articles: follow-up
Displaying 1-3 of 3 results
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November
2007
9
6
Andrew Worster, Doug Richards, Jaqueline Chu, Kevin Eva, Nazanin Meshkat
Introduction: Numerous patients are assessed in the emergency department (ED) for chest pain suggestive of acute coronary syndrome (ACS) and subsequently discharged if found to be at low risk. Exercise stress testing is frequently advised as a follow-up investigation for low-risk patients; however, compliance with such recommendations is poorly understood. We sought to determine if compliance with follow-up for exercise stress testing is higher in patients for whom the investigation is ordered at the time of ED discharge, compared with patients who are advised to arrange testing through their family physician (FP).
Methods: Low-risk chest pain patients being discharged from the ED for outpatient exercise stress test and FP follow-up were randomized into 2 groups. ED staff ordered an exercise stress test for the intervention group, and the control group was advised to contact their FP to arrange testing. The primary outcome was completion of an exercise stress test at 30 days, confirmed through both patient contact and stress test results. Patients were unaware that our primary interest was their compliance with the exercise stress testing recommendations.
Results: Two-hundred and thirty-one patients were enrolled and baseline characteristics were similar between the 2 groups. Completion of an exercise stress test at 30 days occurred in 87 out of 120 (72.5%) patients in the intervention group and 60 out of 107 (56.1%) patients in the control group. The difference in compliance rates (16.4%) between the 2 groups was statistically significant (χ2 = 6.69, p < 0.001) with a relative risk of 1.29 (95% confidence interval 1.18-1.40), and the results remained significant after a "worst case" sensitivity analysis involving 4 control group cases lost to follow-up. When subjects were contacted by telephone 30 days after the ED visit, 60% of those who were noncompliant patients felt they did not have a heart problem and that further testing was unnecessary.
Conclusion: When ED staff order an outpatient exercise stress test following investigation for potential ACS, patients are more likely to complete the test if it is booked for them before ED discharge. After discharge, many low-risk chest pain patients feel they are not at risk and do not return to their FP for further testing in a timely manner as advised. Changing to a strategy of ED booking of exercise stress testing may help earlier identification of patients with coronary heart disease.
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March
2007
9
2
Alain Vandal, Antoinette Colacone, Bernard Unger, Eddy Lang, Jean-François Boivin, Marc Afilalo, Nathalie Soucy, Ruth Léger, Xiaoqing Xue
Objective: It has been suggested that continuity of care is hampered because of the lack of communication between emergency departments (EDs) and primary care providers. A web-based, standardized communication system (SCS) that enables family physicians (FPs) to visualize information regarding their patients' ED visits was developed. This paper aims to evaluate the impact of this SCS on continuity of care.
Methods: We conducted an open, 4-period crossover, cluster-randomized controlled trial of 23 FP practices. During the intervention phase, FPs received detailed reports via SCS, while in the control phase they received mailed copies of the ED notes. Continuity of care was evaluated with a web questionnaire completed by FPs 21 days after the ED visit. The primary measures of continuity of care were knowledge of ED visit (quality and quantity), patient management and follow-up rate.
Results: We analyzed a total of 2022 ED visits (1048 intervention and 974 control). The intervention group received information regarding the ED visit more often (odds ratio [OR] 3.14, 95% confidence interval [CI] 2.6-3.79), found the information more useful (OR 5.1, 95% CI 3.49-7.46), possessed a better knowledge of the ED visit (OR 6.28, 95% CI 5.12-7.71), felt they could better manage patients (OR 2.46, 95% CI 2.02-2.99) and initiated actions more often following receipt of information (OR 1.62, 95% CI 1.36-1.93). However, there was no significant difference in the follow-up rate at FPs offices (OR 1.25, 95% CI 0.97-1.61).
Conclusion: The use of SCS between an ED and FPs led to significant improvements in continuity of care by increasing the usefulness of transferred information and by improving FPs' perceived patient knowledge and patient management.
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March
2004
6
2
Ammar Hawass, Daphne D. Murray, David G. Urquhart, David M. Maxwell, Mabel D. Ells, Sam G. Campbell, Stacey Ann Ackroyd-Stolarz, Suzanne M. Varley-Doyle
Introduction: The joint Canadian Infectious Diseases Society and Canadian Thoracic Society guidelines for community-acquired pneumonia (CAP) recommend 48-72 hour telephone follow-up of patients discharged from the emergency department (ED). The guidelines provide no evidence supporting this practice, and neither the clinical utility nor the effectiveness of such recommendations has been assessed. Our objective was to assess the utility of a 48-72 hour telephone follow-up protocol for patients discharged from the ED with CAP.
Methods: This was a retrospective chart audit covering a 2-year period (Jan. 3, 1999 to Jan. 3, 2001) after the introduction of a clinical practice guideline (CPG) that included routine 48-72 hour telephone follow-up of patients discharged from the ED with CAP. Eligible patients were identified in the ED database, rates of referral for telephone follow-up were recorded, and 30-day outcomes (death and readmission) for patients referred versus not referred were compared.
Results: During the study period, 867 patients were identified as being eligible for the study. The mean age was 55.7 years (range 16-98 yr), and mean pneumonia severity index (PSI) was 68.9 (range 6-187). Despite the CPG, only 148 patients (17.1%) were referred for telephone follow-up. Age, demographics, comorbidity, clinical status and pneumonia severity were similar for referred and non-referred patients. Thirty-day death (2.5%) and readmission rates (3%) were strongly related to PSI score, but did not differ significantly in the 2 comparison groups.
Conclusion: In this setting, physicians were poorly compliant with a routine telephone follow-up protocol. The likelihood of referral for follow-up did not correlate with pneumonia severity, and follow-up referral did not appear to affect patient outcome. These findings do not support recommendations for routine early follow-up mechanisms beyond those already existing in the community.
