Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study. CAN J EMERG MED. 2015;17:523-531. [PMID: 26062927 DOI: 10.1017/cem.2015.36]

Hypertensive Urgency: An Emergency Department Pipeline to Primary Care Pilot Study

BACKGROUND

Optimal triage of patients with hypertensive urgency (HU) in the emergency department (ED) is not well established. 2017 ACC/AHA hypertension (HTN) guidelines recommend treatment initiation and follow-up within 1 week. Objectives of our pilot study were to evaluate feasibility and impact of directly connecting ED patients with HU to outpatient HTN management on blood pressure (BP) control and ED utilization.

METHODS

ED patients with HU and no primary care physician were scheduled by a referral coordinator for an initial appointment in a HTN clinic embedded within a primary care practice. BP control and ED utilization over the subsequent 90 days were tracked and compared with BP at time of the referral ED visit, and ED utilization in the 90 days preceding referral.

RESULTS

Data are reported for the first 40 referred patients. Average time to first visit was 7.8 days. Mean age was 51 years (range 28-76), 75% were African-American, and mean pooled 10-year atherosclerotic cardiovascular disease (ASCVD) risk was 20.8%. Mean BP declined from 198/116 mm Hg at ED visit to 167/98 mm Hg at HTN clinic visit 1 to 136/83 by 6 weeks and was sustained at 90 days. Total ED visits for the group decreased from 61 in the 90 days prior to referral, to 18 in the 90 days after the first HTN clinic visit.

CONCLUSIONS

In this pilot study, coordinated referral between the ED and primary care provides safe, timely care for this high ASCVD risk population and leads to sustained reductions in BP and ED utilization.

High blood pressure readings on in-store machines: a qualitative study of the perspective of pharmacy staff

OBJECTIVES

Emergency department (ED) visits for high blood pressure are on the rise. Yet the majority of these patients are discharged home after their ED evaluation, particularly those who present following an elevated reading on an in-store pharmacy machine. We aimed to gain insight on the practice and referral patterns of pharmacy staff who encounter a patient with an elevated in-store blood pressure (BP) reading.

METHODS

We conducted a qualitative study using semi-structured interviews with pharmacy staff (pharmacists and pharmacy technicians/assistants) from California, United States and Ontario, Canada. Interview questions were designed to examine the practice and referral patterns of pharmacy staff for patients with elevated in-store BP readings. Standard descriptive content analysis techniques were used to analyze the data and to develop themes for current practice and referral patterns.

RESULTS

Twenty-four interviews were completed: six with pharmacy technicians/assistants and 18 with pharmacists. Canadian pharmacy staff (83%) reported being approached frequently (defined as from weekly up to multiple times per day) by patients concerned about an elevated BP reading on an in-store machine, versus 50% reported by American participants. Participant definition of an elevated BP varied, with systolic values ranging from 120 to 150 mmHg and diastolic values from 60 to 90 mmHg. Participants emphasized the need to converse with and assess their patients prior to providing advice. The most frequently reported advice was to seek referral from an outside health care provider: ED, urgent care, or a primary care practitioner. Severity of the BP reading and symptomatology were reported as determining factors for referring patients to the ED. Pharmacists (92%) reported a lack of corporate and/or governing body policy for managing patients with in-store markedly elevated BP readings.

CONCLUSIONS

Managing patients with an elevated BP reading in the community pharmacy setting is complex and not standardized. Referral to an external health care provider, including the ED, was a common theme. The development of a pharmacy referral tool/algorithm may be helpful to refer in-store patients with elevated BP readings to the most appropriate healthcare resources.

Association of Follow-Up Care With Long-Term Death and Subsequent Hospitalization in Patients With Atrial Fibrillation Who Receive Emergency Care in the Province of Ontario

Background:

Currently, 11% of patients seen in the emergency department for atrial fibrillation die within 1 year of the visit. Our objective was to examine the association of rapid (within 3 days), early (7 days), and basic (30 days) outpatient physician follow-up with short- and long-term outcomes in patients with atrial fibrillation discharged from an emergency department.

Methods:

This retrospective cohort study included all adult patients discharged from one of the 163 emergency departments in Ontario, Canada with a primary diagnosis of atrial fibrillation, 2007 to 2014. We used a landmark analysis with propensity score matching, and logistic regression, to assess all-cause mortality and cardiovascular hospitalizations at 1 year and 90 days, 30-day return emergency visits, and 1-year oral anticoagulation prescription fills.

Results:

In the 10 657 patients with rapid follow-up care who were propensity score matched to a patient with follow-up between days 4 and 7, the hazard of a return emergency visit was reduced by 11% (HR, 0.89 [95% CI, 0.80–0.98]). It was not associated with mortality or hospitalization. In the 17 234 patients with early follow-up who were matched to a patient with care between days 8 and 30, the rate of 1-year mortality was 11% lower (HR, 0.89 [95% CI, 0.81–0.97]) and 1-year hospitalization was 6% lower (HR, 0.94 [95% CI, 0.89–1.00]). Relative to no 30-day care, basic follow-up care was associated with an increased hazard of 90-day hospitalization (HR, 1.32 [95% CI, 1.12–1.56]) but was no longer associated with mortality. In patients with early follow-up, the odds of filling an oral anticoagulation prescription a year later were 64% higher than those without it (OR, 1.64 [95% CI, 1.54–1.78]).

Conclusions:

Compared with follow-up care between days 8 and 30, follow-up within a week after discharge from an emergency department with atrial fibrillation was associated with a reduction in the rate of death and hospitalization within 1 year, an association that was not present with 30-day follow-up.

Effect of early physician follow-up on mortality and subsequent hospital admissions after emergency care for heart failure: a retrospective cohort study

BACKGROUND

The 1-year mortality rate in patients with heart failure who are discharged from an emergency department is 20%. We sought to determine whether early follow-up after discharge from the emergency department was associated with decreased mortality or subsequent admission to hospital.

METHODS

This retrospective cohort study conducted in Ontario, Canada, included adult patients who were discharged from 1 of 163 emergency departments between April 2007 and March 2014 with a primary diagnosis of heart failure. Using a propensity score-matched landmark analysis, we assessed follow-up in relation to mortality and admissions to hospital for cardiovascular conditions.

RESULTS

Of 34 519 patients, 16 274 (47.1%) obtained follow-up care within 7 days and 28 846 (83.6%) within 30 days. Compared with follow-up between day 8 and 30, patients with follow-up care within 7 days had a lower rate of mortality over 1 year (hazard ratio [HR] 0.92; 95% confidence interval [CI] 0.87-0.97), and a reduced rate of admission to hospital over 90 days (HR 0.87, 95% CI 0.80-0.94) and 1 year (HR 0.92; 95% CI 0.87-0.97); the mortality rate over 90 days in this group trended to a lower rate (HR 0.90, 95% CI 0.10-1.00). Follow-up care within 30 days, compared with patients without 30-day follow-up, was associated with a reduction in 1-year mortality (HR 0.89, 95% CI 0.82-0.97) but not admission to hospital (HR 1.02, 95% CI 0.94-1.10). In this group, there was a trend toward an increase in 90-day admission to hospital (HR 1.14, 95% CI 1.00-1.29).

INTERPRETATION

Follow-up care within 7 days of discharge from the emergency department was associated with lower rates of long-term mortality, as well as subsequent hospital admissions, and a trend to lower short-term mortality rates. Timely access to longitudinal care for patients with heart failure who are discharged from the emergency setting should be prioritized.

Physician follow-up and long-term use of evidence-based medication for patients with hypertension who were discharged from an emergency department: a prospective cohort study

BACKGROUND

More than 25% of the population has hypertension. The number of patients seeking care for hypertension in emergency departments has increased by more than 60% in the last decade, with less than 10% of these patients subsequently admitted to hospital. Managing physicians recommend early follow-up to patients who are discharged from the emergency department, but there is a paucity of literature assessing the impact or timing of follow-up on patient outcomes.

METHODS

Using a population-based cohort design, we included patients more than 65 years of age who were discharged from an Ontario emergency department with a primary diagnosis of hypertension between 2007 and 2014. We identified 2 cohorts: an incident cohort, and a cohort in which patients were on no more than 1 class of evidence-based antihypertensive medication at the time of presentation. Using logistic regression, we assessed the association of early follow-up care (within 7 d) and basic care (8-30 d), compared with no care within 30 days, on patient use of a new evidence-based antihypertensive medication 1 year later.

RESULTS

Our study included 2088 patients with a new diagnosis of hypertension (the first cohort), and 6420 patients in the second cohort. Of patients with new diagnoses, 48.2% and 30.2% obtained early and basic follow-up care, respectively, compared with 50.0% and 30.9% of patients in the second cohort. Compared with patients without follow-up care within 30 days, the adjusted odds of filling an evidence-based antihypertensive medication prescription 1 year later in the incident group were 2.36 (95% confidence interval [CI] 1.86-2.99) for those who received early care, and 2.00 (95% CI 1.55-2.58) for those who received basic care. The adjusted odds in the second cohort were 2.12 (95% CI 1.84-2.43) and 1.96 (95% CI 1.69-2.27), respectively.

INTERPRETATION

Early follow-up care after leaving an emergency department with a diagnosis of hypertension was associated with improved long-term use of evidence-based antihypertensive medication. As patients increasingly present to the emergency department for hypertension, a formal, timely follow-up care system could improve patient use of evidence-based antihypertensive medication.

Hot Topic: Global Burden of Treating Hypertension-What is the Role of the Emergency Department?

Hypertension (HTN) is the most common modifiable risk factor for cardiovascular disease (CVD) morbidity and mortality worldwide. Lower- and middle-income countries (LMICs) are projected to bear the vast majority of this disease burden, but local and regional health care delivery systems in these countries are ill equipped to meet this need. Emergency care is receiving increased recognition as a crucial component of public and community health. The rapid evolution of emergency care in LMICs provides a unique opportunity to develop innovative strategies, incorporating existing strengths of emergency departments, to address this paradigm shift in the disease burden associated with HTN on a global scale.

Acute Management of Atrial Fibrillation: From Emergency Department to Cardiac Care Unit

The prevalence of atrial fibrillation is increasing rapidly, resulting in more patients presenting for care in the emergency department and in-hospital settings. To reduce morbidity and mortality, and improve patient quality of life, clinicians working in these settings need to be both current and facile in their approach to management of these patients. Frequent updates to guideline recommendations (based on emerging research) make this challenging for practicing physicians. This article reviews the acute management of atrial fibrillation in the emergency and in-hospital settings, including practical approaches to rhythm and rate control, anticoagulation, and special situations, incorporating the most up-to-date guidelines.

Predictors of obtaining follow-up care in the province of Ontario, Canada, following a new diagnosis of atrial fibrillation, heart failure, and hypertension in the emergency department

OBJECTIVE

Patients with cardiovascular diseases are common in the emergency department (ED), and continuity of care following that visit is needed to ensure that they receive evidence-based diagnostic tests and therapy. We examined the frequency of follow-up care after discharge from an ED with a new diagnosis of one of three cardiovascular diseases.

METHODS

We performed a retrospective cohort study of patients with a new diagnosis of heart failure, atrial fibrillation, or hypertension, who were discharged from 157 non-pediatric EDs in Ontario, Canada, between April 2007 and March 2014. We determined the frequency of follow-up care with a family physician, cardiologist, or internist within seven and 30 days, and assessed the association of patient, emergency physician, and family physician characteristics with obtaining follow-up care using cause-specific hazard modeling.

RESULTS

There were 41,485 qualifying ED visits. Just under half (47.0%) had follow-up care within seven days, with 78.7% seen by 30 days. Patients with serious comorbidities (renal failure, dementia, COPD, stroke, coronary artery disease, and cancer) had a lower adjusted hazard of obtaining 7-day follow-up care (HRs 0.77-0.95) and 30-day follow-up care (HR 0.76-0.95). The only emergency physician characteristic associated with follow-up care was 5-year emergency medicine specialty training (HR 1.11). Compared to those whose family physician was remunerated via a primarily fee-for-service model, patients were less likely to obtain 7-day follow-up care if their family physician was remunerated via three types of capitation models (HR 0.72, 0.81, 0.85) or via traditional fee-for-service (HR 0.91). Findings were similar for 30-day follow-up care.

CONCLUSIONS

Only half of patients discharged from an ED with a new diagnosis of atrial fibrillation, heart failure, and hypertension were seen within a week of being discharged. Patients with significant comorbidities were less likely to obtain follow-up care, as were those with a family physician who was remunerated via primarily capitation methods.

Important effect of micronutrient deficiency in inflammatory bowel disease

As is known to all, deficiencies of protein and other nutrients are common symptoms of inflammatory bowel disease (IBD). Nutrient deficiency is not only a manifestation of complicated diseases but also a cause of morbidity. Micronutrient is also the essential material for human health. However, there are few articles elaborating the influence of micronutrient deficiency. At present, choosing available food to keep healthy and to treat diseases is very popular, which is also suitable for IBD patients. Recent studies show that micronutrient deficiencies occur in more than half of patients with IBD, and deficiencies are more common in Crohn's disease than in ulcerative colitis, and in active disease than in disease in remission. Micronutrient deficiencies are associated with prolonged and complicated course of disease. The present review summarizes the effect of micronutrient deficiencies in IBD with regard to the definition of micronutrient, the deficiency status of micronutrient in IBD, the reasons for the lack of micronutrient and the role of micronutrient in the treatment of IBD.

A Population-Based Analysis of Outcomes in Patients With a Primary Diagnosis of Hypertension in the Emergency Department

STUDY OBJECTIVE

Patients treated primarily for hypertension are common in the emergency department (ED). The outcomes of these patients who were given a primary ED diagnosis of hypertension have not been described at a population level. In this study, we describe the characteristics and outcomes of these patients, as well as changes over time.

METHODS

This retrospective cohort study used linked health databases from the province of Ontario, Canada, to assess ED visits made between April 1, 2002, and March 31, 2012, with a primary diagnosis of hypertension. We determined the annual number of visits, as well as the age- and sex-standardized rates. We examined visit disposition and assessed mortality outcomes and potential hypertensive complications at 7, 30, 90, and 365 days and at 2 years subsequent to the ED visit.

RESULTS

There were 206,147 qualifying ED visits from 180 sites. Visits increased by 64% between 2002 and 2012, from 15,793 to 25,950 annual visits, respectively. The age- and sex-standardized rate increased from 170 per 100,000 persons to 228 per 100,000 persons during the same period, a 34% increase. Eight percent of visits ended in hospitalization, but this proportion decreased from 9.9% to 7.1% during the study period. Mortality was very low: less than 1% within 90 days, 2.5% within 1 year, and 4.1% within 2 years. Among subsequent hospitalizations for potential hypertensive complications, stroke was the most frequent admitting diagnosis, but the frequency was still less than 1% at 1 year. Together hospitalizations for stroke, heart failure, acute myocardial infarction, atrial fibrillation, renal failure, hypertensive encephalopathy, and dissection were less than 1% at 30 days.

CONCLUSION

The number of visits made primarily for hypertension has increased significantly during the last decade. Although some of the increase is due to aging of the population, other forces are contributing to it as well. Subsequent mortality and complication rates are low and have declined. With current practice patterns, the feared complications of hypertension are extremely infrequent.

Micronutrient deficiencies in inflammatory bowel disease

PURPOSE OF REVIEW

Malnutrition, protein-energy, and micronutrient deficiencies are common among patients with inflammatory bowel disease (IBD). The deficiencies are a manifestation of the complicated disease and a cause of morbidity. The present review summarizes recent advances and evidence-based knowledge regarding micronutrients in relation to patients with IBD.

RECENT FINDINGS

Micronutrient deficiencies occur in more than half of patients with IBD. Most common are deficiencies of iron, B12, vitamin D, vitamin K, folic acid, selenium, zinc, vitamin B6, and vitamin B1. Deficiencies are more common in Crohn's disease than in ulcerative colitis, and more in active disease than at times of remission. Micronutrient deficiency is associated with prolonged and complicated course of disease. Iron deficiency is the most common cause for anemia. Definite diagnosis of B12 deficiency cannot be established by serum levels alone. Vitamin D and vitamin K deficiencies are thought to be associated with heightened inflammatory state. The relationship of these deficiencies with bone disease is controversial. The present review focuses on the significance, epidemiology, treatment options, and recommendations regarding micronutrient deficiencies in IBD.

SUMMARY

Micronutrient deficiencies are common and have clinical significance. High suspicion for micronutrient deficiencies is advocated so that treatable causes of morbidity are treated appropriately and late and irreversible sequlae are prevented.

Incident atrial fibrillation in the emergency department in Ontario: a population-based retrospective cohort study of follow-up care

BACKGROUND

Continuity of care has been shown to be poor following in-hospital discharge, and there are substantially fewer resources to facilitate follow-up care arrangements after discharge from an emergency department. Our objective was to assess the frequency, timeliness and predictors for obtaining follow-up care following discharge from an emergency department in Ontario with a new diagnosis of atrial fibrillation.

METHODS

We conducted a retrospective cohort study involving all patients discharged from the 157 nonpediatric emergency departments in Ontario, who received a new diagnosis of atrial fibrillation between 2007 and 2012. We determined the frequency of follow-up care with a family physician, cardiologist or internist within 7 (timely) and 30 days of the emergency department visit, and assessed the association of emergency and family physician characteristics, including primary care model type, with obtaining timely follow-up care.

RESULTS

Among 14 907 patients discharged from Ontario emergency departments with a new, primary diagnosis of atrial fibrillation, half (n = 7473) had timely follow-up care. At 30 days, 2678 patients (18.0%) still had not obtained follow-up care. Among emergency and family physician factors, lack of a family physician had the largest independent association with acquiring timely follow-up care (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.50-0.69). Using patients with a family physician belonging to a primarily fee-for-service remuneration model as the comparison group, patients with a family physician belonging to a capitation-based Family Health Network, as part of a Family Health Team, were less likely to receive timely follow-up care (OR 0.73, 95% CI 0.62-0.86), as were those whose family physician belonged to the same model type that was not part of a Family Health Team (OR 0.77, 95% CI 0.60-0.97).

INTERPRETATION

Only half of the patients who were discharged from an emergency department in Ontario with a new diagnosis of atrial fibrillation were seen within 7 days of discharge. The most influential factor was having a family physician; patients with a family physician being remunerated via primarily fee-for-service methods were more likely to be seen within 7 days than those who were reimbursed through a primarily capitation model. Systems-wide solutions are needed to ensure timely follow-up care is available for all patients with chronic diseases.