ORIGINAL ARTICLE
Primary Care Follow-up After Emergency Department Visits for Routine Complaints What Primary Care Physicians Prefer and What Emergency Department Physicians Currently Recommend Jessica Chen, MD and Eric Singer, MD
Objectives: Given that the vast majority of pediatric patients that present to the emergency department (ED) are discharged home after their visit, one issue for study is the appropriate recommendations for follow-up after the ED visit. Numerous PubMed searches using various keywords revealed a gap in the literature regarding the desires of primary care physicians (PCPs) concerning follow-up after ED visits. This study was conducted to determine how pediatric emergency medicine (PEM) physicians' recommendations for follow-up align with the desires of (PCPs) for follow-up after ED visits. Methods: An electronic survey was distributed to pediatric emergency physicians at one community-based academic institution regarding current recommendations for follow-up with PCPs for 12 common diagnoses seen in the ED. A similar survey was sent to pediatricians in the same community inquiring about their desires for follow-up after their patients are seen in the ED for the same diagnoses. Results: Completion rates for the survey were 40/40 (100%) for PEM physicians and 78/145 (54%) for pediatricians. In 11/12 of the diagnoses included, PEM physicians recommended a statistically significant (P < 0.05) closer follow-up than desired by the PCPs. Conclusions: Recommendations for follow-up made by PEM physicians and desired by PCPs vary significantly. Overall, PEM physicians recommend closer follow-up than desired by PCPs for low acuity complaints. Closing of this gap may allow for a better allocation of resources and consistency of care. Key Words: outpatient follow-up, simple infections, simple injuries (Pediatr Emer Care 2016;32: 371–376)
E
mergency department (ED) patients present with a wide variety of complaints. Although some patients come to the ED for urgent, potentially life-threatening conditions, a fair proportion of patients who visit the ED present for conditions appropriate for primary care physicians (PCPs). These patients choose to go to the ED for complaints that could be cared for by their PCP for a number of reasons. Studies have been carried out to investigate why these patients choose EDs rather than visiting their PCPs. Masso et al1 surveyed patients and reported that patients choose the ED over their PCPs mostly due to the perception that their health problem requires immediate attention, the ability to see a physician and have necessary diagnostics done in a single location, and feeling that their health problem was too serious or complex for their PCPs to address. Parents who have had difficulty From the Akron Children’s Hospital. Disclosure: The authors declare no conflict of interest. Reprints: Jess Chen, MD, 1 Perkins Square, Akron, OH 44308 (e‐mail: [email protected]). Funding: This article was supported by a grant from Akron Children’s Hospital. We would also like to acknowledge M. David Gothard, MS of Biostats, Inc for his assistance with statistical analysis. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161
getting care from a PCP without long waits in the past are more likely to bring their child to the ED for nonurgent complaints.2 The Healthcare Cost and Utilization Project published a statistical brief reviewing ED trends across 23 states in the United States in 2005.3 The brief included about 55 million ED visits, 12.4 million of which were for children younger than 18 years (22.7%). Factors associated with higher rates of ED presentation included young age (0–4 years), male sex, and residence in micropolitan or poor community areas. Injuries and respiratory infections were the most common complaints. The majority of children seen in the ED were discharged home (92.7%). This proportion is higher than adult patients, where about 76.5% were treated and released. In pediatric patients, the top 10 most common reasons for ED visits can be grouped into 2 categories: simple injuries, and simple infections. Simple injuries included superficial injuries or bruises, open wounds to arms and legs, sprains and strains, open wounds to extremities, fractures of the arm, and other injuries due to external causes. These injuryrelated diagnoses made up 26.3% of pediatric ED visits. Another 25.3% of pediatric ED visits were due to infectious-related diagnoses of upper respiratory infections (includes a mix of nose, throat, and trachea infections), otitis media, fever, and viral infections. On average, 99.1% of pediatric patients that present with these 10 diagnoses are treated and released.3 Given that the vast majority of pediatric patients that present to the ED are discharged home after their visit, one issue for study is the appropriate recommendations for follow-up after the ED visit. Numerous PubMed searches using various keywords revealed a gap in the literature regarding the desires of PCPs concerning follow-up after ED visits. Studies do exist that examine patient compliance with follow-up recommendations. Wang et al4 found that, within their study group, 60.4% of patients visited their PCPs when instructed to do so. A statistically significant factor in predicting better compliance with follow-up was having private insurance (76.8% compliance compared to 46.5% with public or no insurance). Among the privately insured, having a high acuity diagnosis made follow-up more likely (80% compliance versus 38.5% compliance with low acuity diagnoses). Within the underinsured group, patients with English-speaking caregivers had better compliance than patients with caregivers that were not English-speaking (58% compared to 40% compliance in nonEnglish speaking subgroup).2 Similarly, Liberman et al5 studied follow-up with PCPs after pediatric ED visits for respiratory tract illnesses and found a follow-up rate of only 23.6%. When the population was subdivided, they found that patients with acute conditions were more likely to follow-up than patients with asthma, which was the only chronic condition included. This pattern held true when the data were adjusted for age, insurance type, triage acuity, distance from patient’s home to PCP, and provision of explicit discharge instructions.5 These results suggest that patients may not be convinced of the necessity of follow-up, especially for low acuity complaints.
Pediatric Emergency Care • Volume 32, Number 6, June 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
www.pec-online.com
371
Pediatric Emergency Care • Volume 32, Number 6, June 2016
Chen and Singer
Studies have shown that patients who are given specific recommendations for PCP follow-up within a certain timeframe are more likely to follow-up than patients who are told to follow-up as needed or do not receive instruction to follow-up.5,6 Followup appointments are more likely to be scheduled and kept when a specific time frame for follow-up is given.6 Patients had a 70% higher rate of follow-up when given explicit follow-up instructions in Liberman et al's study.5 This study was performed to clarify the degree of importance PCPs place on follow-up visits for several specific low acuity diagnoses, determine follow-up recommendations given by ED physicians, and clarify how PCPs' desires compare with what ED physicians currently recommend. Our hypothesis was that ED physicians recommend follow-up in these cases more frequently and with a shorter timeframe than desired by PCPs. Aligning the desires of pediatricians with the recommendations of ED physicians may result in higher satisfaction of PCPs and patients. If follow-up can be optimized based on the desires of pediatricians, the financial burden on the system might also decrease.
METHODS A list of local pediatricians was obtained from the Medical Staff Office of Akron Children's Hospital. Akron Children's Hospital employs primary care pediatricians at twenty offices in the surrounding community. These physicians as well as independent community pediatricians were included. Survey Monkey was used to create 2 separate electronic surveys, 1 for community pediatricians and 1 for pediatric ED physicians. Institutional review board approval was obtained, and a hospital-funded grant was obtained to fund statistical analysis. The surveys were distributed by e-mail. Community pediatricians were asked about their preference for follow-up after their patients were seen in the ED for 12 routine complaints. Responders were asked to assume these were otherwise healthy children who improved with time after their visits to the ED. Children who had complicated courses with these diagnoses were excluded. Seven options for follow-up were included: none, in office in 1–2 days, in office in 3–5 days, in office in 1–2 weeks, and by phone with the same time frames. Physician demographical information was also collected. Community pediatricians were also asked if their desires for follow-up differ depending on whether patients were seen at a community ED versus a pediatric ED. A similar survey was created for pediatric emergency physicians employed by the hospital regarding their current recommendations for PCP follow-up after these same complaints. The survey was sent monthly for 5 months to capture as many responders as possible electronically. Attempts were made to contact nonresponders by phone or mail.
Statistical Analysis Data was analyzed using SPSS v17.0 software after download and import from the Survey Monkey website. Summaries of respondents for each presenting diagnosis were stratified according to whether the respondent was a community pediatrician or an ED physician. The summaries consisted of the frequencies and percentages of responses for each follow-up category for each of 12 diagnoses. Analysis focused on determining the diagnoses for which a discrepancy existed between the pediatricians’ wishes for follow-up and the ED physicians’ recommendations for follow-up. A χ2 test for the distributional equality of follow-up recommendations was performed between the two strata of physicians
372
www.pec-online.com
for each diagnosis. The discordance was then determined if the null hypothesis of distributional equality is rejected at a 5% 2sided α significance level.
RESULTS A total of 150 area pediatricians were contacted. Five were found to no longer be in practice, making the final sample 145. Seventy-eight (53.8%) responded to the survey. Forty-one (52.6%) of the responders were hospital-employed pediatricians (Table 1). Consideration was given to the possibility that pediatricians who spend time moonlighting in the ED might have a different opinion on follow-up. Only 7 (9.7%) of the responders reported that they ever moonlight in the ED setting. Inquiries were made about scheduling opportunities for patients who call requesting appointments. Seventy-three (96.1%) pediatricians worked in practices that reserved appointments for patients who are acutely ill or need to follow-up after being seen in the ED. Many practices offered extended hours on weekends (61, 78.2%) or evenings (37, 47.4%). All 40 emergency physicians currently working in the ED responded to the survey. Of these physicians, 17 (42.5%) had completed a pediatric emergency medicine fellowship and 9 (22.5%) were current fellows. The remainder (35%) were general pediatricians who work in the ED. Because scheduling urgent appointments creates the biggest burden on a pediatric practice, initial analysis focused on recommended follow-up within 5 days of an ED visit (Table 2). For the diagnosis of asthma, most pediatric ED physicians and pediatricians agreed that follow-up should occur within 5 days. However, for all other diagnoses, ED physicians recommended follow-up within 5 days, which differed from what the pediatricians desired. For example, with the diagnosis of urticaria, 75% of ED physicians recommend follow-up within 5 days, and only 24.4% of pediatricians wanted follow-up to occur within 5 days (P < 0.001). Similarly, for streptococcal pharyngitis, 37.5% of pediatric ED physicians recommended follow-up within 5 days and only 1.3% of pediatricians shared this viewpoint (P < 0.001). Many pediatricians did not feel that an office visit for follow-up was necessary for these diagnoses (73.1% for urticaria and 87.2% for streptococcal pharyngitis). Significant differences were also found for the diagnoses of ankle sprain (P = 0.0254), acute otitis media (P < 0.001), urinary tract infection (P < 0.001), gastroenteritis with mild dehydration (P < 0.001), pneumonia (P < 0.018), TABLE 1. Physician Demographics and Subject Characteristics Physician Type/Variable Primary care physician Pediatrician at Akron Children's Hospital Pediatrics Office 41 (52.6%) Moonlight in ED 7 (9.7%) Type of extended hours offered by practice None 13 (6.7%) Weekend 61 (78.2%) Evening 37 (47.4%) Practice reserves spots for sick 73 (96.1%) visits/ED follow-up visits Pediatric emergency medicine Completed pediatric emergency medicine fellowship 17 (42.5%) Current fellow 9 (22.5%) Number of ER shifts/month—mean (SD) 12.5 (4.42)
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Pediatric Emergency Care • Volume 32, Number 6, June 2016
Primary Care Follow-up After ED Visits
TABLE 2. Comparison of Pediatrician Follow-up Recommendations Within 5 Days
Diagnosis
Follow-Up
Recommendation
ED Physicians Recommending
PCPs Desiring
Follow-up in 1–5 Days (%)
Follow-up in 1–5 Days (%)
Difference (%)
P*
47.5 37.5 37.5 72.5 90 77.5 85 62.5 37.5 45 75 52.5
27 6.4 1.3 24.4 82.1 29.5 64.1 34.6 2.6 7.7 24.4 20.5
20.5 31.1 36.2 48.1 7.9 48 20.9 27.9 34.9 37.3 50.6 32
0.0254†
Primary Care Follow-up After Emergency Department Visits for Routine Complaints What Primary Care Physicians Prefer and What Emergency Department Physicians Currently Recommend Jessica Chen, MD and Eric Singer, MD
Objectives: Given that the vast majority of pediatric patients that present to the emergency department (ED) are discharged home after their visit, one issue for study is the appropriate recommendations for follow-up after the ED visit. Numerous PubMed searches using various keywords revealed a gap in the literature regarding the desires of primary care physicians (PCPs) concerning follow-up after ED visits. This study was conducted to determine how pediatric emergency medicine (PEM) physicians' recommendations for follow-up align with the desires of (PCPs) for follow-up after ED visits. Methods: An electronic survey was distributed to pediatric emergency physicians at one community-based academic institution regarding current recommendations for follow-up with PCPs for 12 common diagnoses seen in the ED. A similar survey was sent to pediatricians in the same community inquiring about their desires for follow-up after their patients are seen in the ED for the same diagnoses. Results: Completion rates for the survey were 40/40 (100%) for PEM physicians and 78/145 (54%) for pediatricians. In 11/12 of the diagnoses included, PEM physicians recommended a statistically significant (P < 0.05) closer follow-up than desired by the PCPs. Conclusions: Recommendations for follow-up made by PEM physicians and desired by PCPs vary significantly. Overall, PEM physicians recommend closer follow-up than desired by PCPs for low acuity complaints. Closing of this gap may allow for a better allocation of resources and consistency of care. Key Words: outpatient follow-up, simple infections, simple injuries (Pediatr Emer Care 2016;32: 371–376)
E
mergency department (ED) patients present with a wide variety of complaints. Although some patients come to the ED for urgent, potentially life-threatening conditions, a fair proportion of patients who visit the ED present for conditions appropriate for primary care physicians (PCPs). These patients choose to go to the ED for complaints that could be cared for by their PCP for a number of reasons. Studies have been carried out to investigate why these patients choose EDs rather than visiting their PCPs. Masso et al1 surveyed patients and reported that patients choose the ED over their PCPs mostly due to the perception that their health problem requires immediate attention, the ability to see a physician and have necessary diagnostics done in a single location, and feeling that their health problem was too serious or complex for their PCPs to address. Parents who have had difficulty From the Akron Children’s Hospital. Disclosure: The authors declare no conflict of interest. Reprints: Jess Chen, MD, 1 Perkins Square, Akron, OH 44308 (e‐mail: [email protected]). Funding: This article was supported by a grant from Akron Children’s Hospital. We would also like to acknowledge M. David Gothard, MS of Biostats, Inc for his assistance with statistical analysis. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161
getting care from a PCP without long waits in the past are more likely to bring their child to the ED for nonurgent complaints.2 The Healthcare Cost and Utilization Project published a statistical brief reviewing ED trends across 23 states in the United States in 2005.3 The brief included about 55 million ED visits, 12.4 million of which were for children younger than 18 years (22.7%). Factors associated with higher rates of ED presentation included young age (0–4 years), male sex, and residence in micropolitan or poor community areas. Injuries and respiratory infections were the most common complaints. The majority of children seen in the ED were discharged home (92.7%). This proportion is higher than adult patients, where about 76.5% were treated and released. In pediatric patients, the top 10 most common reasons for ED visits can be grouped into 2 categories: simple injuries, and simple infections. Simple injuries included superficial injuries or bruises, open wounds to arms and legs, sprains and strains, open wounds to extremities, fractures of the arm, and other injuries due to external causes. These injuryrelated diagnoses made up 26.3% of pediatric ED visits. Another 25.3% of pediatric ED visits were due to infectious-related diagnoses of upper respiratory infections (includes a mix of nose, throat, and trachea infections), otitis media, fever, and viral infections. On average, 99.1% of pediatric patients that present with these 10 diagnoses are treated and released.3 Given that the vast majority of pediatric patients that present to the ED are discharged home after their visit, one issue for study is the appropriate recommendations for follow-up after the ED visit. Numerous PubMed searches using various keywords revealed a gap in the literature regarding the desires of PCPs concerning follow-up after ED visits. Studies do exist that examine patient compliance with follow-up recommendations. Wang et al4 found that, within their study group, 60.4% of patients visited their PCPs when instructed to do so. A statistically significant factor in predicting better compliance with follow-up was having private insurance (76.8% compliance compared to 46.5% with public or no insurance). Among the privately insured, having a high acuity diagnosis made follow-up more likely (80% compliance versus 38.5% compliance with low acuity diagnoses). Within the underinsured group, patients with English-speaking caregivers had better compliance than patients with caregivers that were not English-speaking (58% compared to 40% compliance in nonEnglish speaking subgroup).2 Similarly, Liberman et al5 studied follow-up with PCPs after pediatric ED visits for respiratory tract illnesses and found a follow-up rate of only 23.6%. When the population was subdivided, they found that patients with acute conditions were more likely to follow-up than patients with asthma, which was the only chronic condition included. This pattern held true when the data were adjusted for age, insurance type, triage acuity, distance from patient’s home to PCP, and provision of explicit discharge instructions.5 These results suggest that patients may not be convinced of the necessity of follow-up, especially for low acuity complaints.
Pediatric Emergency Care • Volume 32, Number 6, June 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
www.pec-online.com
371
Pediatric Emergency Care • Volume 32, Number 6, June 2016
Chen and Singer
Studies have shown that patients who are given specific recommendations for PCP follow-up within a certain timeframe are more likely to follow-up than patients who are told to follow-up as needed or do not receive instruction to follow-up.5,6 Followup appointments are more likely to be scheduled and kept when a specific time frame for follow-up is given.6 Patients had a 70% higher rate of follow-up when given explicit follow-up instructions in Liberman et al's study.5 This study was performed to clarify the degree of importance PCPs place on follow-up visits for several specific low acuity diagnoses, determine follow-up recommendations given by ED physicians, and clarify how PCPs' desires compare with what ED physicians currently recommend. Our hypothesis was that ED physicians recommend follow-up in these cases more frequently and with a shorter timeframe than desired by PCPs. Aligning the desires of pediatricians with the recommendations of ED physicians may result in higher satisfaction of PCPs and patients. If follow-up can be optimized based on the desires of pediatricians, the financial burden on the system might also decrease.
METHODS A list of local pediatricians was obtained from the Medical Staff Office of Akron Children's Hospital. Akron Children's Hospital employs primary care pediatricians at twenty offices in the surrounding community. These physicians as well as independent community pediatricians were included. Survey Monkey was used to create 2 separate electronic surveys, 1 for community pediatricians and 1 for pediatric ED physicians. Institutional review board approval was obtained, and a hospital-funded grant was obtained to fund statistical analysis. The surveys were distributed by e-mail. Community pediatricians were asked about their preference for follow-up after their patients were seen in the ED for 12 routine complaints. Responders were asked to assume these were otherwise healthy children who improved with time after their visits to the ED. Children who had complicated courses with these diagnoses were excluded. Seven options for follow-up were included: none, in office in 1–2 days, in office in 3–5 days, in office in 1–2 weeks, and by phone with the same time frames. Physician demographical information was also collected. Community pediatricians were also asked if their desires for follow-up differ depending on whether patients were seen at a community ED versus a pediatric ED. A similar survey was created for pediatric emergency physicians employed by the hospital regarding their current recommendations for PCP follow-up after these same complaints. The survey was sent monthly for 5 months to capture as many responders as possible electronically. Attempts were made to contact nonresponders by phone or mail.
Statistical Analysis Data was analyzed using SPSS v17.0 software after download and import from the Survey Monkey website. Summaries of respondents for each presenting diagnosis were stratified according to whether the respondent was a community pediatrician or an ED physician. The summaries consisted of the frequencies and percentages of responses for each follow-up category for each of 12 diagnoses. Analysis focused on determining the diagnoses for which a discrepancy existed between the pediatricians’ wishes for follow-up and the ED physicians’ recommendations for follow-up. A χ2 test for the distributional equality of follow-up recommendations was performed between the two strata of physicians
372
www.pec-online.com
for each diagnosis. The discordance was then determined if the null hypothesis of distributional equality is rejected at a 5% 2sided α significance level.
RESULTS A total of 150 area pediatricians were contacted. Five were found to no longer be in practice, making the final sample 145. Seventy-eight (53.8%) responded to the survey. Forty-one (52.6%) of the responders were hospital-employed pediatricians (Table 1). Consideration was given to the possibility that pediatricians who spend time moonlighting in the ED might have a different opinion on follow-up. Only 7 (9.7%) of the responders reported that they ever moonlight in the ED setting. Inquiries were made about scheduling opportunities for patients who call requesting appointments. Seventy-three (96.1%) pediatricians worked in practices that reserved appointments for patients who are acutely ill or need to follow-up after being seen in the ED. Many practices offered extended hours on weekends (61, 78.2%) or evenings (37, 47.4%). All 40 emergency physicians currently working in the ED responded to the survey. Of these physicians, 17 (42.5%) had completed a pediatric emergency medicine fellowship and 9 (22.5%) were current fellows. The remainder (35%) were general pediatricians who work in the ED. Because scheduling urgent appointments creates the biggest burden on a pediatric practice, initial analysis focused on recommended follow-up within 5 days of an ED visit (Table 2). For the diagnosis of asthma, most pediatric ED physicians and pediatricians agreed that follow-up should occur within 5 days. However, for all other diagnoses, ED physicians recommended follow-up within 5 days, which differed from what the pediatricians desired. For example, with the diagnosis of urticaria, 75% of ED physicians recommend follow-up within 5 days, and only 24.4% of pediatricians wanted follow-up to occur within 5 days (P < 0.001). Similarly, for streptococcal pharyngitis, 37.5% of pediatric ED physicians recommended follow-up within 5 days and only 1.3% of pediatricians shared this viewpoint (P < 0.001). Many pediatricians did not feel that an office visit for follow-up was necessary for these diagnoses (73.1% for urticaria and 87.2% for streptococcal pharyngitis). Significant differences were also found for the diagnoses of ankle sprain (P = 0.0254), acute otitis media (P < 0.001), urinary tract infection (P < 0.001), gastroenteritis with mild dehydration (P < 0.001), pneumonia (P < 0.018), TABLE 1. Physician Demographics and Subject Characteristics Physician Type/Variable Primary care physician Pediatrician at Akron Children's Hospital Pediatrics Office 41 (52.6%) Moonlight in ED 7 (9.7%) Type of extended hours offered by practice None 13 (6.7%) Weekend 61 (78.2%) Evening 37 (47.4%) Practice reserves spots for sick 73 (96.1%) visits/ED follow-up visits Pediatric emergency medicine Completed pediatric emergency medicine fellowship 17 (42.5%) Current fellow 9 (22.5%) Number of ER shifts/month—mean (SD) 12.5 (4.42)
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Pediatric Emergency Care • Volume 32, Number 6, June 2016
Primary Care Follow-up After ED Visits
TABLE 2. Comparison of Pediatrician Follow-up Recommendations Within 5 Days
Diagnosis
Follow-Up
Recommendation
ED Physicians Recommending
PCPs Desiring
Follow-up in 1–5 Days (%)
Follow-up in 1–5 Days (%)
Difference (%)
P*
47.5 37.5 37.5 72.5 90 77.5 85 62.5 37.5 45 75 52.5
27 6.4 1.3 24.4 82.1 29.5 64.1 34.6 2.6 7.7 24.4 20.5
20.5 31.1 36.2 48.1 7.9 48 20.9 27.9 34.9 37.3 50.6 32
0.0254†
