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

Published online by Cambridge University Press:  21 May 2015

Doug Richards ,
Nazanin Meshkat ,
Jaqueline Chu ,
Kevin Eva  and
Andrew Worster
Doug Richards*
Affiliation:
Department of Medicine, McMaster University, Hamilton, Ont.
Nazanin Meshkat
Affiliation:
Department of Medicine, University of Toronto, Toronto, Ont.
Jaqueline Chu
Affiliation:
Department of Medicine, McMaster University, Hamilton, Ont.
Kevin Eva
Affiliation:
Clinical Epidemiology and Biostatics, McMaster University, Hamilton, Ont.
Andrew Worster
Affiliation:
Department of Medicine, McMaster University, Hamilton, Ont.
*
237 Barton St. East, Hamilton ON L8L 2X2; richardsdouglaslorne@hotmail.com

Abstract

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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 (χ2 = 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 FP for further testing in a timely manner as advised. Changing to a strategy of ED booking of exercise stress testing may help earlier identification of patients with coronary heart disease.

Keywords

complianceadherenceexercise stress testlow-risk chest painfollow-up
Type
Original Research • Recherche originale
Information
Canadian Journal of Emergency Medicine , Volume 9 , Issue 6 , November 2007 , pp. 435 - 440
Copyright
Copyright © Canadian Association of Emergency Physicians 2007

References

1.Hill, S, Devereaux, PJ, Griffith, L, et al. Can troponin I measurement predict short-term serious cardiac outcomes in patients presenting to the emergency department with possible acute coronary syndrome? CJEM 2004;6:22–30.CrossRefGoogle Scholar
2.Pope, JH, Aufderheide, TP, Ruthazer, R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000;342:1163–70.Google Scholar
3.Christenson, J, Innes, G, McKnight, D, et al. Safety and efficiency of emergency department assessment of chest discomfort. CMAJ 2004;170:1803–7.CrossRefGoogle ScholarPubMed
4.Gibbons, RJ, Balady, GJ, Bricker, JT, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee to Update the 1997 Exercise Testing Guidelines. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol 2002;40:1531–40.CrossRefGoogle Scholar
5.Meyer, M, Mooney, R, Sekera, A. A critical pathway for patients with acute chest pain and low risk for short-term adverse cardiac events: role of outpatient stress testing. Ann Emerg Med 2006;47:435.e1–3.Google Scholar
6.Murray, MJ, LeBlanc, CH. Clinic follow-up from the emergency department: Do patients show up? Ann Emerg Med 1996;27:56–8.CrossRefGoogle ScholarPubMed
7.Thomas, EJ, Burstin, HR, O’Neil, AC, et al. Patient noncompliance with medical advice after the emergency department visit. Ann Emerg Med 1996;27:49–55.Google Scholar
8.Lewin, K. Group decision and social change. In: Swanson, GE, Newcombe, TM, and Hartley, EL, editors. Readings in social psychology. New York (NY): Henry Holt; 1952.Google Scholar
9.Baren, JM, Shofer, FS, Ivey, B, et al. A randomized, controlled trial of simple emergency department intervention to improve the rate of primary care follow-up for patients with acute asthma exacerbations. Ann Emerg Med 2001;38:115–22.Google Scholar
10.Zorc, JJ, Scarfone, RJ, Li, Y, et al. Scheduled follow-up after a pediatric emergency department visit for asthma: a randomized trial. Pediatrics 2003;111:495–502.CrossRefGoogle ScholarPubMed