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Predictors of obtaining follow-up care in the province of Ontario, Canada, following a new diagnosis of atrial fibrillation, heart failure, and hypertension in the emergency department

  • Clare L. Atzema (a1) (a2) (a3), Bing Yu (a1), Noah M. Ivers (a1) (a4) (a5), Paula A. Rochon (a1) (a6) (a5), Douglas S. Lee (a1) (a7) (a8), Michael J. Schull (a1) (a2) (a3) and Peter C. Austin (a1)...

Abstract

Objective

Patients with cardiovascular diseases are common in the emergency department (ED), and continuity of care following that visit is needed to ensure that they receive evidence-based diagnostic tests and therapy. We examined the frequency of follow-up care after discharge from an ED with a new diagnosis of one of three cardiovascular diseases.

Methods

We performed a retrospective cohort study of patients with a new diagnosis of heart failure, atrial fibrillation, or hypertension, who were discharged from 157 non-pediatric EDs in Ontario, Canada, between April 2007 and March 2014. We determined the frequency of follow-up care with a family physician, cardiologist, or internist within seven and 30 days, and assessed the association of patient, emergency physician, and family physician characteristics with obtaining follow-up care using cause-specific hazard modeling.

Results

There were 41,485 qualifying ED visits. Just under half (47.0%) had follow-up care within seven days, with 78.7% seen by 30 days. Patients with serious comorbidities (renal failure, dementia, COPD, stroke, coronary artery disease, and cancer) had a lower adjusted hazard of obtaining 7-day follow-up care (HRs 0.77-0.95) and 30-day follow-up care (HR 0.76-0.95). The only emergency physician characteristic associated with follow-up care was 5-year emergency medicine specialty training (HR 1.11). Compared to those whose family physician was remunerated via a primarily fee-for-service model, patients were less likely to obtain 7-day follow-up care if their family physician was remunerated via three types of capitation models (HR 0.72, 0.81, 0.85) or via traditional fee-for-service (HR 0.91). Findings were similar for 30-day follow-up care.

Conclusions

Only half of patients discharged from an ED with a new diagnosis of atrial fibrillation, heart failure, and hypertension were seen within a week of being discharged. Patients with significant comorbidities were less likely to obtain follow-up care, as were those with a family physician who was remunerated via primarily capitation methods.

Objectif

Les cas de maladie cardiovasculaire sont fréquents au service des urgences (SU), et il faut s’assurer de la poursuite des soins après les consultations afin que les patients soient soumis à des examens de diagnostic et à des traitements fondés sur des données probantes. Nous avons donc examiné la fréquence du suivi médical après que des malades eurent obtenu leur congé du SU suivant la pose d’un nouveau diagnostic de l’une des trois maladies cardiovasculaires mentionnées en titre.

Méthode

Nous avons procédé à une étude de cohorte rétrospective parmi des patients chez qui avait été posé un nouveau diagnostic d’insuffisance cardiaque, de fibrillation auriculaire ou d’hypertension et qui avaient obtenu leur congé de l’un des 157 SU non pédiatriques en Ontario, entre avril 2007 et mars 2014. La fréquence du suivi par les médecins de famille, les cardiologues ou les internistes a été déterminée pour des délais de 7 jours et de 30 jours suivant la consultation, et des associations ont été établies entre différentes caractéristiques des patients, des médecins d’urgence et des médecins de famille quant à l’obtention d’une consultation de suivi, à l’aide de la modélisation des risques par cause.

Résultats

Au total, 41 485 consultations au SU respectaient les critères de sélection. Tout juste un peu moins de la moitié des patients (47,0 %) ont obtenu une consultation de suivi dans les 7 jours suivant la consultation au SU, et 78,7 % ont été examinés au bout de 30 jours. Les patients souffrant de maladies concomitantes graves (insuffisance rénale, démence, BPCO, accident vasculaire cérébral, maladie coronarienne ou cancer) avaient un risque rajusté d’obtention d’une consultation de suivi au bout de 7 jours (rapport des risques instantanés [RRI] : 0,77-0,95) et de 30 jours (RRI : 0,76-0,95) moins élevé que les autres. La seule caractéristique des médecins d’urgence associée au suivi était la formation spécialisée en médecine d’urgence, d’une durée de 5 ans (RRI : 1,11). Les patients dont le médecin de famille était rémunéré selon l’un des trois types de modèle de paiement par patient (RRI : 0,72; 0,81; 0,85) ou selon le modèle traditionnel de paiement à l’acte (RRI : 0,91) étaient moins susceptibles d’obtenir une consultation de suivi au bout de 7 jours que ceux dont le médecin de famille était principalement rémunéré selon un modèle de paiement au service. Il en allait de même pour les consultations de suivi au bout de 30 jours.

Conclusions

Seule la moitié des patients ayant obtenu leur congé du SU, chez qui avait été posé un nouveau diagnostic de fibrillation auriculaire, d’insuffisance cardiaque ou d’hypertension ont pu obtenir une consultation médicale au cours de la semaine suivante. Les patients souffrant de maladies concomitantes graves étaient moins susceptibles d’obtenir une consultation de suivi, tout comme ceux dont le médecin de famille était principalement rémunéré selon un modèle de paiement par patient.

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Copyright

Corresponding author

Correspondence to: Dr. Clare Atzema, Institute of Clinical Evaluative Sciences, 2075 Bayview Avenue, Rm G146, Toronto ON M4N 3M5; Email: clare.atzema@ices.on.ca

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