Can a Novel Intervention Improve Patient Follow-Up After ED Discharge?

Background: Follow-up with a primary care (PC) provider is an important part of healthcare.  Many countries have a robust outpatient system, and the US is no different. However, in the US, there are many challenges to follow up including: appointment availability, insurance status, unclear discharge instructions and socioeconomic status.  Removing some of these barriers by scheduling an appointment before ED discharge could potentially increase outpatient follow up. Use of a simple, low resource bedside intervention that schedules follow-up appointments prior to ED discharge could improve health outcomes and decrease return ED visits.

What They Did:

• Pilot, parallel, randomized controlled trial of discharged patients whom treating physicians determined PC follow-up was important and possessed health insurance but had no PC provider to one of three groups:
  • Booking Group:A PC appointment booked through the booking website prior to ED discharge
    • Used a free physician appointment-booking website (Zocdoc) which allows users to book an appointment at a desired date and time with a PC provider who accepts the patient’s insurance within a predetermined radius of the patient’s zip code
  • Booking Website Information Group:Written information on how to use the booking website
  • Usual care(i.e. standard follow-up instructions)
• Patients were called 2 weeks after the ED visit to determine whether they had completed a PC follow-up visit

Outcomes:

• Primary: Completed a PC follow-up visit according to self-report
• Secondary:
  • Satisfaction with ED visit
  • Satisfaction with process of obtaining a PC appointment
  • Subsequent ED visits
  • Recovery from the initial health problem 

Inclusion:

• ≥18 years of age
• Being discharged from the ED
• Spoke English
• Had an email address
• Insured
• No PC provider (or wanted a new PC provider)
• ED provider considered PC follow-up within 14 days important (Rated on a visual analogue scale from 0 = Not Important to 10 = Very Important). Scores of ≥5 = Moderately Important, were defined as important and meeting study inclusion

Exclusion:

• Patient did not want a PC provider
• Patient did not want to schedule a PC follow-up visit
• No email access
• Prisoners
• Psychiatric chief complaint
• Kaiser health insurance (Kaiser not listed on the booking website) 

Results:

• 272 patients were enrolled and randomized
• 68% completed the 2 week follow up
• Self-Reported PC Follow-Up Rate:
  • Booking Group: 52% (95% CI -1% to 34%)
  • Booking Website Information Group: 25% (95% CI -32% to 7%)
  • Usual Care Group: 36%
• Extremely or Very Satisfied with Obtaining a PC Appointment:
  • Booking Group: 78%
  • Booking Website Information Group: 54%
  • Usual Care Group: 40%
  • P = 0.003
• Subsequent ED Visits:
  • Booking Group: 13%
  • Booking Website Information Group: 14%
  • Usual Care Group: 8%

Strengths:

• Novel intervention, with minimal cost and time requirements that could have impact on patient care
• Almost all patients that were randomized received their allocated intervention
• Attempted 7 phone calls to ensure robust follow up. (Despite this ≈30% of patients were lost to follow up)
• Baseline characteristics between groups were similar

Limitations:

• Small, single center study. This intervention would require validation in other systems to prove usefulness
• No patient-oriented outcomes
• The insurance status overall was 31% commercial, 35% Medicaid, 22% Medicare, and 12% self-pay. This may not be the insurance status in many systems and could limit generalizability of these results
• Enrollment was a convenience sample and not consecutive patients only occurring 9am – 10pm on weekdays and 9am – 6pm on weekends
• Although Zocdoc is a free website for patients, PC practices must pay to be listed on the site
• Huge exclusion of patients due to the fact patients either had an established PCP or were not wanting a new PCP provider.This may work better in a system where not as many patients already have PCPs.
• Self-reported outcomes are subject to recall biases (See Discussion)
• There was no confirmation that appointments were kept
• Telephone follow-up rate was moderate, but effected the power of this study to detect statistical differences between groups
• Excluded non-English speaking patients which limits any conclusions in this population of patients
• 68% follow up rate in this study isn’t very robust.A 32% non-follow up could really swing results of the study in any direction in terms of statistical significance

Discussion:

• 45% of this patient population had a bachelor’s degree or better. This is very different than the patient populations for which I care for that often don’t even have a high school diploma/GED, which is a patient population that needs more help navigating the medical system IMHO.
• 61% of this patient population had private insurance.My payer mix (and that of may others) is very different with higher uninsured rates
• Recall bias is a systematic error that occurs when participants do not remember previous events or experiences accurately or omit details. Recall bias is a problem in studies that have self-reporting.
• This is not the first study to show that booking a PC follow up appointment prior to discharge improves follow up rates:
  • Atzema CI et al [2]: 5 RCTs reviewed. Increasing the frequency of follow-up with PC after ED discharge was most improved by scheduling a follow-up appointment time prior to ED discharge (NNT 4.3 – 6.3)
  • O’Brien GM et al [3]: 189 adults who did not have a PCP were scheduled for a PC appointment prior to discharge vs usual care. Patients with PCP scheduled appointment were twice as likely to keep the PC appointment compared to usual care (30% vs 14%), but there was no significant difference in ED utilization by these patients in the 12 month follow up period (47% vs 47%)
  • Sin DD et al [4]: 125 asthmatic patients randomized to usual care vs enhanced care which was follow-up appointment made with PCP prior to ED discharge. The enhanced care groups had a higher rate of follow-up compared to usual care (78% vs 25%)
  • Zorc JJ et al [5]: 278 patients with asthma more likely to follow up with appointment scheduled prior to ED discharge compared to usual care (64% vs 46%)
  • Kyriacou DN et al [6]: 250 patients randomized to follow-up appointment prior to ED discharge vs usual care. Follow-up rates were higher in the intervention group compared to the usual care group (59% vs 37%)
• Self-reported compliance with PC follow-up was not different between patients receiving booking website information and usual care in this study. This suggests that the extra step taken in the ED to schedule a follow-up appointment makes a difference in patient follow up rates

Author Conclusion: “Among ED patients that providers judged PC follow-up is important, using a booking website to schedule an appointment before ED discharge resulted in a higher but not statistically significant self-reported PC follow-up rate. This intervention warrants further investigation in a study with a larger sample size and objective follow-up visit data.”

Clinical Take Home Point: This is yet another promising study to show how ED providers can improve the transition of care from the acute ED care to the ambulatory outpatient PC environment. This study did not however find that scheduling an appointment prior to ED discharge changed satisfaction with the ED visit, subsequent use of the ED, or improved patient outcomes.

References:

1. Merritt RJ et al. Randomized Controlled Trial to Improve Primary Care Follow-Up Among Emergency Department Patients. AJEM 2019. PMID: 31402234
2. Atzema CI et al. The Transition of Care Between Emergency Department and Primary Care: A Scoping Study. Acad Emerg Med 2017. PMID: 27797435
3. O’Brien GM et al. Enhanced Emergency Department Referral Improves Primary Care Access Am J Manag Care 1999. PMID: 10622992
4. Sin DD et al. Effects of Increased Primary Care Access on Process of Care and Health Outcomes Among Patients with Asthma who Frequent Emergency Departments. Am J Med 2004. PMID: 15464704
5. Zorc JJ et al. Scheduled Follow-Up After a Pediatric Emergency Department Visit for Asthma: A Randomized Trial. Pediatrics 2003. PMID: 12612227
6. Kyriacou DN et al. Brief Report: Factors Affecting Outpatient Follow-Up Compliance of Emergency Department Patients. J Gen Intern Med 2005. PMID: 16191142

Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami) and Jenny Beck-Esmay, MD (Twitter: @jbeckesmay)

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