Effects of early physician follow-up
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* Finlay A. McAlister

I read with interest the report by Atzema and colleagues on the association between early physician follow-up after an emergency department visit for heart failure and lower rates of subsequent death and hospital admission in Ontario.1 Although the authors’ choice of a 30-day landmark analysis meant that they had to exclude the 4036 events that occurred in the first 30 days after discharge from the emergency department (arguably the period with the highest risk), their findings closely mirror those reported from Alberta in studies using time-dependent covariate analyses to capture early (within the first 30 days) as well as late events and to adjust for differences in time to follow-up visits.2,3

Although Atzema and colleagues’ analysis is based on the assumption that all physician follow-up visits are the same, this neglects the rich literature on the benefits of continuity in medical care.4 For example, my colleagues and I found that patients with heart failure who saw a familiar physician in follow-up rather than just any physician exhibited an additional 10% (after hospital discharge)2 or 11% (after emergency department discharge)3 lower rate of death or hospital admission at 12 months. This apparent benefit associated with continuity accrued early: patients with heart failure seen within 14 days after discharge from hospital or an emergency department exhibited lower rates of 30-day death, hospital admission or emergency department visit if seen by a familiar physician (25.2%, adjusted hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.82–0.89) than if seen by an unfamiliar physician (26.9%, adjusted HR 0.93, 95% CI 0.87–0.996) or not seen in follow-up (47.5%).5

Thus, I would go further than Atzema and colleagues and suggest that system-based approaches should focus on promoting early follow-up of patients with heart failure with health care providers who know the patient, because both promptness of follow-up and continuity modulate subsequent outcomes.

## Footnotes

*   **Competing interests:** None declared.

## References

1.  Atzema CL, Austin PC, Yu B, et al. Effect of early physician follow-up on mortality and subsequent hospital admissions after emergency care for heart failure: a retrospective cohort study. CMAJ 2018;190:E1468–77.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMjoiMTkwLzUwL0UxNDY4IjtzOjQ6ImF0b20iO3M6MjI6Ii9jbWFqLzE5MS8xOC9FNTA5LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  McAlister FA, Youngson E, Bakal JA, et al. Impact of physician continuity on death or urgent readmission after discharge among patients with heart failure. CMAJ 2013;185:E681–9.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTg1LzE0L0U2ODEiO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTkxLzE4L0U1MDkuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

3.  Sidhu RS, Youngson E, McAlister FA. Physician continuity improves outcomes for heart failure patients treated and released from the emergency department. JACC Heart Fail 2014; 2: 368–76.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiamhmIjtzOjU6InJlc2lkIjtzOjc6IjIvNC8zNjgiO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTkxLzE4L0U1MDkuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

4.  Pereira Gray DJ, Sidaway-Lee K, White E, et al. Continuity of care with doctors — A matter of life and death? A systematic review of continuity of care and mortality. BMJ Open 2018;8:e021161.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NzoiYm1qb3BlbiI7czo1OiJyZXNpZCI7czoxMToiOC82L2UwMjExNjEiO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTkxLzE4L0U1MDkuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

5.  McAlister FA, Youngson E, Kaul P, et al. Early follow-up after a heart failure exacerbation: the importance of continuity. Circ Heart Fail 2016;9: e003194.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NjoiY2lyY2hmIjtzOjU6InJlc2lkIjtzOjExOiI5LzkvZTAwMzE5NCI7czo0OiJhdG9tIjtzOjIyOiIvY21hai8xOTEvMTgvRTUwOS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=)