The aim of this study is to quantify ED-generated follow-up adherence rates amongst white, Black American, and Hispanic patients discharged from the ED of a managed care system.
Problem Statement
Previous studies have established that the adherence rates to ED-generated referrals are below par. These rates range between 26% and 56% amongst different ED populations (Kyriacou et al., 2005) even though higher (68 and 71.4%) and lower (17%) rates have been reported (Friedman, Dios, & Hannenman, 2010; Saroff, Dell, & Brown, 2001). The reasons for the poor compliance have also been identified. Amongst the commonly cited reasons is the problem of accessibility due to lack of primary care providers and insurance cover. Notably, majority of these studies have evaluated different aspects of nonadherence and the reasons there of. The design and implementation of concrete solutions to the problem of noncompliance requires more specific information on what factors affect which ED population and to what extent. Some studies have tried to be more specific by attempting to eliminate certain barriers through pre-scheduling of patient appointments before discharge (Kyriacou et al., 2005) and utilization of a capitated managed care system (Saroff, Dell, & Brown, 2001). None of these studies has focused on eliminating the influence of multiple factors though and the only study that was conducted in a managed care set up is limited by its retrospective design.
Rationale for Conducting the Study
Adherence to ED-generated outpatient referrals is influenced by patient, provider, and health care system- related variables (Kyricou et al., 2005). Elimination of the impact of health care system-related access barriers will, through elimination of confounding, help in the identification of other key barriers to follow up and in effect, quantification of the problem they pose and in the creation of sustainable solutions.
Relevance to Nursing
Nurses play a key role in discharge planning for patients in ED settings. Discharge planning in the ED is important in ensuring continuity of care and in mitigating health care costs (Han, Barnard, & Chapman, 2009). Noncompliance with ED referrals is, therefore, an issue of concern to nursing because it impacts negatively on patient outcomes, increases utilization of emergency departments, and leads to misuse of personnel time and resources.
Ethical Considerations
Authority to conduct the study will be sought from the Institutional review board of the managed care system. Oral and written informed consent shall be obtained from all participants to be enrolled for the study.
Literature Review
The number of emergency department visits in the US each year is approximated to be 110 million (Kyriacou et al., 2005). Of these patients, an estimated 45% are referred for further follow-up in outpatient clinics with either a physician or a specialist. Follow-up is important for a number of reasons such as ensuring proper continuation of treatment for the initial condition, management of complications and treatment failures, identification of misdiagnoses, and identification of patient non-adherence to treatment plans (Becker 1985 as cited in Kyriacou et al., 2005). In spite of the essential role of follow-up in ensuring delivery of quality health care, findings from an array of studies suggest that adherence to ED recommended follow-up in the United States is often very poor. It is estimated to range between 26% and 56% amongst different ED populations (Kyriacou et al., 2005) even though higher (68 and 71.4%) and lower (17%) rates have been reported (Friedman, Dios, & Hannenman, 2010; Saroff, Dell, & Brown, 2001). Elderly patients have higher (Friedman, Dios, & Hannenman, 2010) whilst minority populations tend to have lower adherence rates (James, Smith, & Brice, 2009). In regards to diagnosis, some diagnoses are related to high and low rates of ED follow-up. Different rates of adherence have been reported for the same diagnosis though. For instance, a study by Vukmir et al. (1992 as cited in Saroff, Dell, & Brown, 2001) reported that the overall adherence rate for patients with acute fractures referred for ED follow up was 63.3% whilst a more recent study by Saroff, Dell, & Brown (2001) reported an adherence rate of 94.9%. The consequences of non-completion of follow-up depend on the patient’s acuity but generally, nonattendance of follow-up leads to poor patient health outcomes, misuse of resources, and overuse of ED personal time (Friedman, Dios, & Hannenman, 2010).
The reasons that contribute to noncompletion of follow-up are multifactorial and can be clustered into patient, provider, and health system related variables. Previous studies have identified poor communication and physical barriers as factors that contribute to patients’ nonadherence to ED follow-up (Friedman, Dios, & Hannenman, 2010). Sarver and Baker (2000 as cited in Friedman, Dios, & Hannenman, 2010) established that language barriers did not have any significant impact on patient completion of appointments. Clarke et al. (2005 as cited in Friedman, Dios, & Hannenman, 2010), on the other hand, reported that patient adherence was correlated to their understanding of discharge instructions. Kyriacou et al. (2005) reported that lack of insurance and lack of access to a primary care physician were correlated to lower rates of follow-up in the US although their findings were not statistically significant. Thomas et al. (2009 as cited in Friedman, Dios, & Hannenman, 2010) established that failure to pre-schedule ED follow-up appointment was independently linked to missing of follow-up appointments. The same study further established that lack of insurance cover and dissatisfaction with the instructions given at discharge were independently correlated with not filling prescriptions. A study by Friedman, Dios, & Hannenman (2010) identified the primary reasons for nonattendance of ED referrals as patient choice, communication failure, and consultant declination of the appointment. The patients in the latter study had been referred for follow up in specialty (cardiology, internal medicine, and neurology) clinics.
Notably, some of the barriers such as language barrier and lack of a primary care physician do not apply uniformly across different populations. A study by James, Smith, & Brice (2010) that compared adherence to ED discharge instructions and barriers to follow-up across Caucasian, Hispanics, and African-American participants concluded that the differences in the rates of completion of follow-up between the three groups were nonsignificant. Importantly though, the reasons given for non-adherence by the participants in the three groups were different although the differences failed to reach statistical significance. Black and Hispanic subjects (49% and 34% respectively) reported difficulties in scheduling a follow up appointment within two weeks of ED discharge whilst white subjects (30%) cited feeling better as the chief reasons for noncompletion of follow-up. Decreased accessibility is, therefore, one of the reasons why non-adherence is more prevalent amongst minority populations.
Of further note is that the various studies have reported mixed findings on the potential impact of cost on completion of ED-generated outpatient referrals. The Kyricaou et al. (2005) study reported that lack of medical cover reduced follow-up compliance although the rates did not reach statistical significance. The James, Smith, & Brice (2010) study, on the other hand, concluded that the perceived cost of follow-up was not a significant barrier to attendance. This was despite the fact the number of uninsured persons varied across the groups studied. A Canadian study by Saroff, Dell, & Brown (2001) that sought to eliminate barriers to follow up access reported an ED referral compliance rate of 94.9%. This retrospective study reviewed patient compliance with ED-generated referrals in a capitated managed care set up that is a health care system where physicians are paid a uniform salary, members contribute equal per capita, that has its own hospitals, and a mechanism for transiting from the ED to an outpatient clinic. The generalizability of the findings of the study is hampered by its retrospective design and the fact that it enrolled participants with only one diagnosis, acute fractures.
Other studies have tried to improve follow-up by minimizing the impact of barriers such as difficulties in scheduling a follow-up appointment. The Kyricaou et al. (2005) study is one such study. Participants in the study were randomized to two groups. Subjects in the intervention group had their follow-up appointments scheduled for them before discharge. Participants in the control group were given a phone number and instructed to schedule their follow-up appointments on their own. The follow-up completion rates were 55% and 37% for the intervention and control groups respectively (p<.001). A study by Zorc et al. (2009) that sought to improve ED follow-up completion rates by implementing an ED based educational intervention for parents of children managed for asthma failed to produce significant results. The study, however, impacted on the personal beliefs of the parents regarding the importance of follow-up.
Summary of Literature
Adherence to ED-generated follow-up is essential in the delivery of quality health care. The findings of a number of studies, however, suggest that ED follow-up compliance is below par in the US (Kyriacou et al., 2005). Nonadherence has adverse consequences on patient health-related outcomes (Saroff, Dell, & Brown, 2001). The reasons that contribute to noncompletion of follow-up are multifactorial and can be clustered into patient, provider, and health system related variables. They include difficulties in accessing follow-up due to either lack of primary care provider, insurance cover, transport, or someone to take the patient for the follow up appointment; physical barriers; poor communication; poor comprehension of discharge instructions; and dissatisfaction with the instructions given at discharge (Friedman, Dios, & Hannenman, 2010; Kyricaou et al., 2005). Some of these barriers for instance decreased accessibility appear to affect minority groups more (James, Smith, & Brice, 2010). Of note is that the studies that have attempted to eliminate the influence of barriers to follow-up have reported mixed findings (Zorc et al., 2009; Kyriacou et al., 2005).
References
Friedman, S.M., Dios, J. V., & Hannenman, K. (2010). Noncompletion of referrals to outpatient specialty clinics among patients discharged from the emergency department: a prospective cohort study. Canadian Journal of Emergency Medicine, 12(4), 325-330.
James, T. D., Smith, P. C., & Brice, P. H. (2010). Self-reported discharge instruction adherence among different racial groups seen in the emergency department. Journal of the National Medical Association, 102 (10), 931-936.
Kyriacou, D. N., Dan Handel, M. D., Stein, A. C., & Nelson, R. R. (2005). Brief report: Factors affecting outpatient follow-up compliance of emergency department patients. Journal of General Internal Medicine, 20(10), 938-942.
Saroff, D., Dell, R., & Brown, E. R. (2002). International Journal for Quality Health Care, 14(2), 149-153.
Zorc J. J., Chew, A., & Shaw, K. (2009). Beliefs and barriers to follow-up after an emergency department asthma visit: A randomized trial. Pediatrics, 124 (4), 1135-1142.
Han, C.Y., Barnard, A., & Chapman, H. (2009). Emergency department nurses' understanding and experiences of implementing discharge planning. Journal of Advanced Nursing, 65(6), 1283-1292.
