Emergency department patient compliance with follow-up for outpatient exercise stress testing: a randomized controlled trial

Abstract

Introduction:Numerous patients are assessed in the emergency department (ED) for chest pain suggestive of acute coronary syndrome (ACS) and subsequently discharged if found to be at low risk. Exercise stress testing is frequently advised as a follow-up investigation for low-risk patients; however, compliance with such recommendations is poorly understood. We sought to determine if compliance with follow-up for exercise stress testing is higher in patients for whom the investigation is ordered at the time of ED discharge, compared with patients who are advised to arrange testing through their family physician (FP). Methods: Low-risk chest pain patients being discharged from the ED for outpatient exercise stress test and FP follow-up were randomized into 2 groups. ED staff ordered an exercise stress test for the intervention group, and the control group was advised to contact their FP to arrange testing. The primary outcome was completion of an exercise stress test at 30 days, confirmed through both patient contact and stress test results. Patients were unaware that our primary interest was their compliance with the exercise stress testing recommendations. Results: Two-hundred and thirty-one patients were enrolled and baseline characteristics were similar between the 2 groups. Completion of an exercise stress test at 30 days occurred in 87 out of 120 (72.5%) patients in the intervention group and 60 out of 107 (56.1%) patients in the control group. The difference in compliance rates (16.4%) between the 2 groups was statistically significant (χ 2 = 6.69, p < 0.001) with a relative risk of 1.29 (95% confidence interval 1.18-1.40), and the results remained significant after a "worst case" sensitivity analysis involving 4 control group cases lost to follow-up. When subjects were contacted by telephone 30 days after the ED visit, 60% of those who were noncompliant patients felt they did not have a heart problem and that further testing was unnecessary. Conclusion: When ED staff order an outpatient exercise stress test following investigation for potential ACS, patients are more likely to complete the test if it is booked for them before ED discharge. After discharge, many low-risk chest pain patients feel they are not at risk and do not return to their ORIGINAL RESEARCH • RECHERCHE ORIGINALE

Evaluación del impacto clínico y la seguridad de una unidad de dolor torácico en pacientes con probabilidad baja e intermedia de síndrome coronario agudo

“…La adherencia a este proceso de atención fue incompleta debido a que solo al 45,4% de los pacientes se les realizó la prueba diagnóstica ambulatoria. El estudio de Richards et al 30 reportó mayores promedios de cumplimiento de la prueba diagnóstica y de la cita de valoración por cardiología, cuando la prueba fue agendada previo al alta del paciente. Este no fue siempre posible en nuestra muestra de pacientes.…”

Compliance with stress testing in patients discharged from the emergency department following a diagnosis of low-risk chest pain

“…Compliance rates improve significantly when outpatient stress tests are organised prior to discharge, Meyer demonstrated a 92.2% compliance rate for EST when the procedure was booked prior to discharge, and Richards showed that compliance improved from 56.1% for patients advised to see their PCP to organise the procedure, to 72.5% for patients who had their EST booked prior to discharge 2 17. The efficacy of this strategy is based on the premise that the fewer steps an individual must take to reach a goal, the more likely they are to complete it.…”

Incident atrial fibrillation in the emergency department in Ontario: a population-based retrospective cohort study of follow-up care

“…Research CMAJ OPEN been reported for older patients who have visited emergency departments (regardless of need for follow-up), 35 with better rates (73%) among patients with chest pain who were directly referred for a stress test. 36 The patient with newly diagnosed atrial fibrillation who has not received follow-up care is likely to have gone unprotected from a stroke; however, the risk is …”