Elsevier

American Heart Journal

Volume 168, Issue 3, September 2014, Pages 289-295
American Heart Journal

Clinical Investigation
Coronary Artery Disease
The role of primary care physician and cardiologist follow-up for low-risk patients with chest pain after emergency department assessment

https://doi.org/10.1016/j.ahj.2014.05.016Get rights and content

Background

Chest pain is one of the most common reasons for presentation to the emergency department (ED); however, there is a paucity of data evaluating the impact of physician follow-up and subsequent management. To evaluate the impact of physician follow-up for low-risk chest pain patients after ED assessment.

Methods

We performed a retrospective observational study of low-risk chest pain patients who were assessed and discharged home from an Ontario ED. Low risk was defined as ≥50 years of age and no diabetes or preexisting cardiovascular disease. Follow-up within 30 days was stratified as (a) no physician, (b) primary care physician (PCP) alone, (c) PCP with cardiologist, and (d) cardiologist alone. The primary outcome was death or myocardial infarction (MI) at 1 year.

Results

Among 216,527 patients, 29% had no-physician, 60% had PCP-alone, 8% had PCP with cardiologist, and 4% had cardiologist-alone follow-up after ED discharge. The mean age of the study cohort was 64.2 years, and 42% of the patients were male. After adjusting for important differences in baseline characteristics between physician follow-up groups, the adjusted hazard ratios for death or MI were 1.07 (95% CI 1.00-1.14) for the PCP group, 0.81 (95% CI 0.72-0.91) for the PCP with cardiologist group, and 0.87 (95% CI 0.74-1.02) for the cardiologist alone group, as compared with patients who had no follow-up.

Conclusion

In this cohort of low-risk patients who presented to an ED with chest pain, follow-up with a PCP and cardiologist was associated with significantly reduced risk of death or MI at 1 year.

Section snippets

System context

The Canadian health insurance system provides free universal coverage for all essential ambulatory and emergency medical services for all its citizens. Patients do not have to pay any fees when seeking assessment in the ED or seeing PCP or cardiologists in the outpatient setting. The Ontario Drug Benefit program is a government-funded drug benefit program that covers outpatient drug costs for all Ontario residents aged ≥65 years.

Study sample

Our study sample included low-risk patients discharged home from

Study population

Of the 805,760 patients who presented to an Ontario ED with chest pain between April 1, 2004, and March 31, 2010, we excluded 115,332 patients because of hospitalization from the ED, 29,919 patients who had repeat visits with chest pain or were hospitalized with an acute coronary syndrome within 30 days, and 1,626 patients who died within 30 days of assessment. Patients who were not assigned a physician group such as seeing a noncardiology specialist (52,421 patients) and patients with

Discussion

Our study extends current knowledge in the transition of care after ED assessment for patients with chest pain. Despite practice guidelines recommending physician follow-up after chest pain evaluation, 29% of patients did not visit any physician in 30 days after ED assessment.3, 4 Importantly, we found that PCP with cardiologist follow-up was associated with 19% reduced hazard of death or MI and 27% reduced hazard of death compared with no follow-up. Patients who saw a cardiologist alone at

References (13)

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Dr Lee is supported by a Canadian Institutes of Health Research (CIHR) (Ottawa, Ontario, Canada) Clinician Scientist Award. Dr Schull is supported by a CIHR Applied Chair in Health Services and Policy Research. Dr Tu is supported by a Canada Research Chair in Health Services Research and a Career Investigator Award from the Heart and Stroke Foundation of Ontario (Toronto, Ontario, Canada). Dr Wijeysundera is supported by a Distinguished Clinical Scientist Award from the Heart and Stroke Foundation of Canada. Dr Ko is supported by a Clinician Scientist Award from the Heart and Stroke Foundation of Ontario.

This study was supported by the Institute for Clinical Evaluative Sciences (Toronto, Ontario, Canada), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (Ontario, Canada). There are no financial relationships with any organizations that might have an interest in the submitted work in the previous 2 years; no other relationships or activities that could appear to have influenced the submitted work. None of the listed organizations endorse this study nor do they have any influence on its publication.

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