Access to Heart Failure Care Post ED Visit
Access to Heart Failure Care Post ED Visit
The primary goal of establishing benchmarks and/or guidelines is to ensure adherence to quality health care that optimizes patient outcomes. We found that less than a third of patients consulted with a physician subsequent to an ED visit for HF within the recommended 2-week benchmark. Patients who consulted a physician within 4weeks were at significantly lower risk for an AE.
In our study, the adherence to the recommended 2-week timeline for consultation subsequent to an ED visit was 30.2%. This is lower than the 39% adherence rate with respect to a guideline of 8-week follow-up of patients who were newly prescribed statin therapy. The authors of this latter study suggest that the low adherence to this guideline stems from difficulty to schedule patients within the "short" timeframe of 8weeks. In our study, the timeframe of 2weeks is much shorter and underscores this difficulty even further. Other barriers, which may explain our low rate of adherence, may include a lack of awareness and/or disagreement with the actual guideline, lack of published correlation of patient outcomes with delay to consultation, physician's availability, and patient-related barriers.
We observed disparities in follow-up post ED visit with respect to predisposing factors (higher educational level and older age) and perception of need (systolic dysfunction HF and not taking HF medications before ED visit). Higher educational level is generally associated with higher socioeconomic status, which has been linked with better access to HF care. Older persons are more likely to have a follow-up appointment scheduled. Persons who were not taking HF medications may have a more urgent need for follow-up because they may have not received care for HF in the past. The tendency for those persons who had systolic dysfunction HF to be followed sooner may reflect the perception that this is a more serious type of HF.
In our cohort, 34.6% of patients had an AE within 6months, and 21% of patients had an AE within 3months. Hastings et al reported a higher rate of AEs within 3months (33%) among elderly patients subsequent to ED visit in the United States. These authors studied patients with all diagnoses and also included admission to a nursing home as an AE (we had only 2 patients admitted to nursing homes during follow-up). Furthermore, their study period spanned from 2000 to 2002; ours was during 2007 to 2010, and patient management may have improved. Our finding of lower risk for AE in patients with early physician consultation after ED visit for HF is in agreement with several studies that use administrative data bases demonstrating that early medical follow-up was associated with better outcomes.
Our clinical study was useful in identifying potential clinical factors that would not be available in administrative data bases such as information on HRQOL and LVEF. Besides follow-up post ED visit, we found that having a lower self-reported HRQOL, having a previous history of myocardial infarction, and having preserved systolic function were associated with having an AE. These may be indicators of more severe disease. Persons with systolic dysfunction may be diagnosed and managed sooner, whereas those with preserved systolic function HF may have more severe disease when they are recognized putting them at higher risk for AE.
The strengths of our study are confirmed primary diagnosis of HF in all enrolled patients as well as the collection of both patient reported data and information from the medical chart. The main limitation is the possibility of selection bias due to exclusion of patients with incomplete data. Patients with missing information had a higher mortality rate and more comorbidities. If these patients were less likely to have early follow-up, our results may underestimate the importance of early consultation to prevent an AE. Another limitation is our reliance on patient self-report for follow-up consultation information (when this information was not recorded in the medical chart). Patients may not be accurate in reporting the time of their consultation with a physician. However, we believe that inaccuracies with timing of the consultation with a physician by patients were not frequent within the relatively short time interval of 6 weeks to their first telephone interview. We did not measure attitudes and beliefs of ED physicians: some ED physicians may be biased in that they label HF as a low-risk disease and possibly do not insist on rapid follow-up of these patients. Future research is also needed to investigate processes of care with respect to this poor rate of follow-up. Finally, we did not address provider availability, although patients were recruited in urban hospital EDs where there is a relatively high concentration of cardiologists compared with more rural centers.
The conclusions are (1) less than a third of patients with an ED visit for HF are followed up within the recommended time frame of 2weeks; (2) older patients with higher education were more likely to have timely medical follow-up; and (3) patients with medical follow-up within 2 to 4weeks post ED visit have fewer AEs. Discharge planning and interventions that improve care transitions may decrease readmission and improve health outcomes. There is an urgency to improve HF care by ensuring timely follow-up for all patients with ED visit for HF. It is not enough to issue guidelines or benchmarks; efforts must be made to optimize adherence to these guidelines. Even within the present constraints of our health care system, we should be able to do better to serve HF patients to maximize patient outcomes and prevent AEs as much as possible.
Discussion
The primary goal of establishing benchmarks and/or guidelines is to ensure adherence to quality health care that optimizes patient outcomes. We found that less than a third of patients consulted with a physician subsequent to an ED visit for HF within the recommended 2-week benchmark. Patients who consulted a physician within 4weeks were at significantly lower risk for an AE.
In our study, the adherence to the recommended 2-week timeline for consultation subsequent to an ED visit was 30.2%. This is lower than the 39% adherence rate with respect to a guideline of 8-week follow-up of patients who were newly prescribed statin therapy. The authors of this latter study suggest that the low adherence to this guideline stems from difficulty to schedule patients within the "short" timeframe of 8weeks. In our study, the timeframe of 2weeks is much shorter and underscores this difficulty even further. Other barriers, which may explain our low rate of adherence, may include a lack of awareness and/or disagreement with the actual guideline, lack of published correlation of patient outcomes with delay to consultation, physician's availability, and patient-related barriers.
We observed disparities in follow-up post ED visit with respect to predisposing factors (higher educational level and older age) and perception of need (systolic dysfunction HF and not taking HF medications before ED visit). Higher educational level is generally associated with higher socioeconomic status, which has been linked with better access to HF care. Older persons are more likely to have a follow-up appointment scheduled. Persons who were not taking HF medications may have a more urgent need for follow-up because they may have not received care for HF in the past. The tendency for those persons who had systolic dysfunction HF to be followed sooner may reflect the perception that this is a more serious type of HF.
In our cohort, 34.6% of patients had an AE within 6months, and 21% of patients had an AE within 3months. Hastings et al reported a higher rate of AEs within 3months (33%) among elderly patients subsequent to ED visit in the United States. These authors studied patients with all diagnoses and also included admission to a nursing home as an AE (we had only 2 patients admitted to nursing homes during follow-up). Furthermore, their study period spanned from 2000 to 2002; ours was during 2007 to 2010, and patient management may have improved. Our finding of lower risk for AE in patients with early physician consultation after ED visit for HF is in agreement with several studies that use administrative data bases demonstrating that early medical follow-up was associated with better outcomes.
Our clinical study was useful in identifying potential clinical factors that would not be available in administrative data bases such as information on HRQOL and LVEF. Besides follow-up post ED visit, we found that having a lower self-reported HRQOL, having a previous history of myocardial infarction, and having preserved systolic function were associated with having an AE. These may be indicators of more severe disease. Persons with systolic dysfunction may be diagnosed and managed sooner, whereas those with preserved systolic function HF may have more severe disease when they are recognized putting them at higher risk for AE.
The strengths of our study are confirmed primary diagnosis of HF in all enrolled patients as well as the collection of both patient reported data and information from the medical chart. The main limitation is the possibility of selection bias due to exclusion of patients with incomplete data. Patients with missing information had a higher mortality rate and more comorbidities. If these patients were less likely to have early follow-up, our results may underestimate the importance of early consultation to prevent an AE. Another limitation is our reliance on patient self-report for follow-up consultation information (when this information was not recorded in the medical chart). Patients may not be accurate in reporting the time of their consultation with a physician. However, we believe that inaccuracies with timing of the consultation with a physician by patients were not frequent within the relatively short time interval of 6 weeks to their first telephone interview. We did not measure attitudes and beliefs of ED physicians: some ED physicians may be biased in that they label HF as a low-risk disease and possibly do not insist on rapid follow-up of these patients. Future research is also needed to investigate processes of care with respect to this poor rate of follow-up. Finally, we did not address provider availability, although patients were recruited in urban hospital EDs where there is a relatively high concentration of cardiologists compared with more rural centers.
The conclusions are (1) less than a third of patients with an ED visit for HF are followed up within the recommended time frame of 2weeks; (2) older patients with higher education were more likely to have timely medical follow-up; and (3) patients with medical follow-up within 2 to 4weeks post ED visit have fewer AEs. Discharge planning and interventions that improve care transitions may decrease readmission and improve health outcomes. There is an urgency to improve HF care by ensuring timely follow-up for all patients with ED visit for HF. It is not enough to issue guidelines or benchmarks; efforts must be made to optimize adherence to these guidelines. Even within the present constraints of our health care system, we should be able to do better to serve HF patients to maximize patient outcomes and prevent AEs as much as possible.
