Chest pain patients at highest risk skip follow-up after emergency visit

It sounds counter-intuitive, but patients at highest risk for adverse outcomes may not be those most likely to seek follow-up treatment after being discharged from the emergency department for chest pain, according to research published Feb. 23.

Michael K.Y. Wong of the Sunnybrook Health Sciences Centre at the University of Toronto, and colleagues linked multiple Ontario databases to analyze what factors influenced patient follow-up after chest pain hospital discharge. Data encompassed Ontario-wide emergency department assessments and results for patients presenting with chest pain from 2004 through 2010.

They found patients who were more likely to follow up with a physician or a cardiologist within 30 days of discharge visited a cardiologist (odds ratio 3.01) or primary care physician (6.44) prior to a visit to the emergency department. These patients were also likely to have higher socioeconomic status, diabetes, hypertension, atrial fibrillation or dyslipidemia.

Patients least likely to follow up with any physician were rural, had renal or cerebrovascular disease or had a history of trauma. Patients with dementia (0.36), paralysis (0.61), MI (0.84) or heart failure (0.89) all bore a strong likelihood of lower physician follow-up.

Follow-up specifically with a cardiologist was more likely among patients with a higher socioeconomic status, dyslipidemia, previous admissions for heart failure, arrhythmia or ventricular arrhythmias who were between 50 and 69 and male. Comorbidities, including diabetes, peripheral vascular or cerebrovascular disease, respiratory or neurologic disease, unstable angina, cancer, trauma or depression, marked patients who were less likely to follow up with a cardiologist regarding chest pain after hospital discharge.

Prior studies by the research team noted that physician follow-up after hospital discharge for chest pain significantly reduced risk of MI or death. However, the same study noted one in four high-risk patients failed to follow up with physicians within 30 days of an emergency room visit for chest pain.

Wong et al emphasized the importance of identifying and advocating the more vulnerable patients for missed follow-up care. They recommended that for these patients, scheduling follow-up appointments before discharge may be reasonable.

“Given that many studies have shown the importance of continuity of care during the transitional period between discharge from the emergency department and returning to the community setting, we believe a paradigm shift ensuring follow-up care is needed,” Wong et al wrote.

The study was published in Canadian Medical Association Journal.