Benton R. Hunter, MD reviewing Lin MP et al. JAMA Netw Open 2020 Oct 9
In a study of Medicare patients, outpatient follow-up was associated with a markedly decreased risk for mortality.
To determine the rate of ambulatory follow-up after emergency department (ED) visits and whether there was an association with clinical outcomes, researchers retrospectively analyzed national Medicare data for continuously enrolled beneficiaries aged ≥65 who were discharged from an ED between 2011 and 2016.
The study involved a random sample of 20% of such beneficiaries — including nearly 9.5 million visits to 4728 EDs. The population was 61% female with a mean age of 77.3 years. After accounting for deaths and terminations of Medicare enrollment, the incidence of ambulatory follow-up was 40.5% at 7 days and 70.8% at 30 days. Medicaid eligibility, Black race, and treatment at a rural ED were each associated with decreased likelihood of follow-up. At 30 days, 1.4% of patients had died, 17.4% had revisited an ED, and 9.4% were hospitalized. Ambulatory follow-up was associated with a 51% decrease in mortality at 30 days, but relative increases of 22% in hospitalization rate and 1% in repeat ED visits.
Although this study is limited by confounders and cannot prove causation, the strong association between lack of follow-up and short-term mortality is eye catching. The finding that follow-up was associated with increased return visits and hospitalizations as well as decreased mortality suggests that some returns and hospitalizations may have been lifesaving. We should strive to make sure appropriate follow-up is available to our patients who need it, recognizing that follow-up may be more difficult to obtain for minorities and the economically disadvantaged.