UMEM Educational Pearls

How many times have you discharged a patient with a clinical impression of “abdominal pain” with no clear explanation or diagnosis? 

How many of these times do you direct them to follow up with gastroenterology? And more importantly, how often do they actually do so?

This study discussed a multi-disciplinary approach to ensuring adequate follow up for patients, utilizing an EMR based transition of care (TOC) program. The study stratified patients into 2 groups, pre and post TOC program implementation, to assess rates of appointment scheduling and attendance, as well as rates of return to ED within 30 days. Patients were further stratified based on their Distressed Communities Index (DCI) score (a composite of 7 different socioeconomic metrics) into 5 tiers: Distressed Communities, At Risk Communities, Mid-Tier Communities, Comfortable Communities, and Prosperous Communities. Prior to the implementation of the TOC program, the onus was on the patient to schedule their appointment. The TOC program consisted of an order placed in EMR, which triggered review of the patient's chart by the gastroenterology attending or NP. This individual would then message the information to the appropriate GI subspecialty clinic, along with a time frame in which the patient should be seen. The clinic would then check the patient's insurance reach out to the patient directly to schedule the appointment.

While there was no signifcant difference in 30-day readmission between the pre and post TOC program patients, the post-implementation group was found to both schedule appointments (50% vs 27% p-value <0.01) AND show up to appointments (34% vs 24% p-value <0.01) at significantly higher rates compared to Pre-TOC patients. Additionally, post-TOC patients in the At-Risk and Distressed DCI groups were 22x more likely to follow up than the same groups in the pre-TOC group (OR 22.18, 95% CI 4.23–116.32).

Though the study had promising results, it did admittedly have some limitations, namely the size of the at-risk and distressed groups.  Another consideration, though not mentioned in the paper, is that access to a working phone is necessary to the success of this program. Nevertheless, the idea of a TOC program is worth consideration as a means to ensure that patients are not lost to follow up and potentially reduce the risk of adverse events.

References

Mizrahi J, Marhaba J, Buniak W, Sun E. Transition-of-care program from emergency department to gastroenterology clinics improves follow-up. Am J Emerg Med. 2023;69:154-159. doi:10.1016/j.ajem.2023.04.030