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I read with interest the report by Atzema and colleagues[1] on the association between early physician follow-up after an emergency department (ED) visit for heart failure (HF) and lower rates of subsequent death/hospitalization in Ontario. Although their choice of a 30 day landmark analysis meant that they had to exclude the 4036 events that occurred in the first 30 days after ED discharge (arguably the highest risk period), 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, we found that HF patients who saw a familiar physician in follow-up rather than just any physician exhibited an additional 10% (after hospital discharge)[2] or 11% (after ED discharge)[3] lower rate of death/hospitalization at 12 months. This apparent benefit associated with continuity accrued early: HF patients seen within 14 days after discharge from hospital or an ED exhibited lower rates of 30-day death/hospitalization/ED visit if seen by a familiar physician (25.2%, aHR 0.86, 95% CI 0.82-0.89) compared to unfamiliar physician follow-up (26.9%, aHR 0.93, 95% CI 0.87-0.996) or no 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 HF patients with healthcare providers who know the patient since both promptness of follow-up and continuity modulate subsequent outcomes.
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-E147
2. McAlister FA, Youngson E, Bakal JA, Kaul P, Ezekowitz J, van Walraven C. Impact of physician continuity on death or urgent readmission after discharge among patients with heart failure. CMAJ 2013;185:E681–E689.
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
4. Pereira Gray DJ, Sidaway-Lee K, White E, Thorne A, Evans PH. 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.
5. McAlister FA, Youngson E, Kaul P, Ezekowitz JA. Early Follow-Up After a Heart Failure Exacerbation: The Importance of Continuity. Circ Heart Fail 2016;9:e003194.