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

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.Chest pain is one of the most common presenting symptoms in emergency departments. In Canada, about 500 000 visits to the emergency department are related to chest pain assessment each year.¹ Most of these visits result in discharge after excluding a cardiac diagnosis with an immediate risk of adverse effect.² Current clinical guidelines strongly advocate for patients with chest pain who have been discharged from the emergency department to receive outpatient follow-up with a physician within 72 hours for further assessment or treatment, because many patients remain at risk for future events.³Among patients at high baseline cardiovascular risk who were discharged from the emergency department after assessment of chest pain, our group has previously shown significantly reduced hazard of death or myocardial infarction associated with follow-up with either a primary care physician or a cardiologist within 30 days.² At 1-year postassessment, the rate of death or myocardial infarction was 5.5% among patients who received cardiologist follow-up, 7.7% with primary care follow-up and 8.6% with no physician follow-up.² In addition, we found a considerable gap in practice, with 1 in 4 high-risk patients with chest pain failing to follow-up with a physician within 30 days of assessment in Ontario, Canada.² A better understanding of why physician follow-up does not occur in accordance with guidelines is essential to improve the transition of care from the emergency department to home. Thus, the main objective of our study was to evaluate clinical and nonclinical factors associated with physician follow-up among patients with chest pain after discharge from the emergency department.