Effect of early physician follow-up on mortality and subsequent hospital admissions after emergency care for heart failure: a retrospective cohort study

Abstract

Background: The 1-year mortality rate in patients with heart failure who are discharged from an emergency department is 20%. We sought to determine whether early follow-up after discharge from the emergency department was associated with decreased mortality or subsequent admission to hospital.

Methods: This retrospective cohort study conducted in Ontario, Canada, included adult patients who were discharged from 1 of 163 emergency departments between April 2007 and March 2014 with a primary diagnosis of heart failure. Using a propensity score-matched landmark analysis, we assessed follow-up in relation to mortality and admissions to hospital for cardiovascular conditions.

Results: Of 34 519 patients, 16 274 (47.1%) obtained follow-up care within 7 days and 28 846 (83.6%) within 30 days. Compared with follow-up between day 8 and 30, patients with follow-up care within 7 days had a lower rate of mortality over 1 year (hazard ratio [HR] 0.92; 95% confidence interval [CI] 0.87-0.97), and a reduced rate of admission to hospital over 90 days (HR 0.87, 95% CI 0.80-0.94) and 1 year (HR 0.92; 95% CI 0.87-0.97); the mortality rate over 90 days in this group trended to a lower rate (HR 0.90, 95% CI 0.10-1.00). Follow-up care within 30 days, compared with patients without 30-day follow-up, was associated with a reduction in 1-year mortality (HR 0.89, 95% CI 0.82-0.97) but not admission to hospital (HR 1.02, 95% CI 0.94-1.10). In this group, there was a trend toward an increase in 90-day admission to hospital (HR 1.14, 95% CI 1.00-1.29).

Interpretation: Follow-up care within 7 days of discharge from the emergency department was associated with lower rates of long-term mortality, as well as subsequent hospital admissions, and a trend to lower short-term mortality rates. Timely access to longitudinal care for patients with heart failure who are discharged from the emergency setting should be prioritized.

Figure 1:

Flow chart for study participants. Note: ED = emergency department, GDMT = guideline-directed medical therapy, HF = heart failure, PS = propensity score. *Met outcome within 30 days (Appendix 1, part b, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.180786/-/DC1).

Figure 2:

Kaplan–Meier curve for mortality after discharge from the emergency department (1 yr) in matched patients with heart failure who had follow-up care between days 1 and 7 versus 8 and 30 using propensity score–matched groups. Landmark at 30 days.

Figure 3:

Kaplan–Meier curve for mortality after discharge from the emergency department (90 d) in matched patients with heart failure who had follow-up care between days 1 and 7 versus 8 and 30, using propensity score–matched groups. Landmark at 30 days.