Association Between Physician Follow-Up and Outcomes of Care After Chest Pain Assessment in High-Risk Patients

Study Questions:

What are patterns of physician follow-up among a cohort of chest pain patients with diabetes mellitus or established cardiovascular disease after discharge from the emergency department (ED), and what are relationships between physician follow-up and patterns and outcomes of care?

Methods:

This was an observational study of 56,767 Canadian patients with diabetes mellitus or established cardiovascular disease who were evaluated for chest pain and discharged from the ED. Physician follow-up within 30 days after discharge from the ED was categorized as cardiology, primary care physician (PCP), or none. The primary outcome was a composite of all-cause mortality and recurrent hospitalization for myocardial infarction (MI) at 1 year.

Results:

In the study cohort, 17% of patients were evaluated by cardiologists: 58% by PCPs alone, and 25% had no physician follow-up. Cardiologist follow-up was associated with significantly lower adjusted hazard ratio (HR) of death or MI compared with no physician (HR, 0.79; 95% confidence interval [CI], 0.71-0.88; p < 0.001) and PCP (HR, 0.85; 95% CI, 0.78-0.92; p < 0.001). Within 100 days of discharge from the ED for the assessment of chest pain, patients who had cardiologist follow-up underwent significantly more cardiac diagnostic testing and cardiac invasive procedures, with most testing occurring after the cardiology visit.

Conclusions:

Among high-risk patients with diabetes mellitus or pre-existing cardiovascular disease, one in four patients did not have any physician follow-up within 30 days after discharge from the ED. Compared to patients who had follow-up with a PCP or no follow-up, those who were seen by a cardiologist had a decreased risk of all-cause mortality or hospitalization for MI.

Perspective:

This study establishes the importance of physician follow-up after an ED evaluation for chest pain among a cohort of patients at higher baseline risk for adverse cardiovascular outcomes. Nearly 25% of patients had no follow-up within 30 days, and these patients had an increased risk of mortality at 1 year. While this study alone is inadequate to suggest changes in process measures, support the routine use of particular diagnostic testing or treatment modalities, or specifically identify the aspects of care responsible for the differences between physician groups, it highlights a potential gap in the transition of care in this high-risk population presenting to the ED.

Keywords: Physicians, Risk, Myocardial Infarction, Follow-Up Studies, Process Assessment (Health Care), Chest Pain, Physicians, Primary Care, Canada, Cardiovascular Diseases, Emergency Service, Hospital, Diabetes Mellitus


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