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. Author manuscript; available in PMC: 2023 Sep 8.
Published in final edited form as: Circ Cardiovasc Qual Outcomes. 2022 Sep 8:101161CIRCOUTCOMES122009001. doi: 10.1161/CIRCOUTCOMES.122.009001

Incidence of timely outpatient follow-up care after emergency department encounters for acute heart failure

Austin S Kilaru 1,2,3, Nicholas Illenberger 4, Zachary F Meisel 5,6, Peter W Groeneveld 7, Manqing Liu 8, Angira Mondal 9,10, Nandita Mitra 11, Raina M Merchant 12,13,14
PMCID: PMC9489651  NIHMSID: NIHMS1827631  PMID: 36073354

Abstract

Background

Patients who are discharged from the emergency department (ED) after an encounter for acute heart failure (AHF) are at high risk for return hospitalization. These patients may benefit from timely outpatient follow-up care to reassess volume status, adjust medications, and reinforce self-care strategies. This study examines the incidence of outpatient follow-up care after ED encounters for AHF and describes patient characteristics associated with obtaining timely follow-up care.

Methods

We conducted a retrospective cohort study using an administrative claims database for a large US commercial insurer, from January 1 2012 to June 30 2019. Participants included adult patients discharged from the ED with principal diagnosis of acute heart failure. The primary outcome was obtaining an in-person outpatient clinic visit for heart failure within 30 days. We also examined the competing risk of all-cause hospitalization within 30 days and without an intervening outpatient clinic visit. We estimated competing risk regression models to identify patient characteristics associated with obtaining outpatient follow-up and report cause-specific hazard ratios.

Results

The cohort included 52732 patients, with mean age of 73.9 years (95%CI 73.8 to 74.0) and 27395 (52.0%; 95%CI 51.5 to 52.4) female patients. Within 30 days of the ED encounter, 12279 (23.2%) patients attended an outpatient clinic visit for heart failure, with 8382 (15.9%) patients hospitalized before they could obtain an outpatient clinic visit. In the adjusted analysis, patients that were younger, women, reporting non-Hispanic Black race, and had fewer previous clinic visits were less likely to obtain outpatient follow-up care.

Conclusions

Few patients obtain timely outpatient follow-up after ED visits for heart failure, although nearly 20% require hospitalization within 30 days. Improved transitions following discharge from the ED may represent an opportunity to improve outcomes for patients with AHF.

Keywords: Heart failure, emergency medicine, continuity of patient care, health services, healthcare disparities

Introduction

Each year, there are nearly 1 million visits to the emergency department (ED) for acute heart failure (AHF) in the United States.1–3 Most of those visits – nearly 80 percent – lead to hospitalization.1,4 Patients with AHF often have clear indications for inpatient care, including critical care interventions, diagnostic procedures, and symptom management.5 Yet one quarter of hospitalized AHF patients are discharged within 48 hours, some of whom may be eligible for discharge after initial evaluation and treatment in the ED.1,5–7

Unfortunately, AHF patients are at high risk for adverse outcomes even when they are discharged from the ED, including death and rehospitalization.8–14 After an ED visit, patients require time-sensitive outpatient management, including assessment of volume status, medication adjustment, and reinforcement of self-care strategies.15,16 Early follow-up care for AHF has been shown to improve outcomes after hospital discharge.17–20 While this benefit is less clear after ED discharge, few hospitals offer clinical pathways or care coordination services to support patients who are discharged from the ED.21–24 In fact, access to outpatient follow-up care may influence the decision to hospitalize AHF patients, including those with mild or resolving symptoms.11,15,16,25,26 The responsibility for arranging follow-up care is often placed on patients and their families, many of whom will encounter barriers in accessing timely primary or specialty care.27–29

Few studies have described the important transition from the ED to outpatient care.10,24,30–32 Several risk stratification tools have been developed to predict outcomes for AHF patients in the ED, but these instruments do not consider the impact of follow-up care.26,33–39 One study from an integrated health system reported that nearly 75 percent of AHF patients obtained follow-up care within 7 days of an ED encounter.10 Understanding the proportion of AHF patients in the general population who obtain outpatient follow-up can inform future interventions to improve outcomes, including transitional care management, remote monitoring, home health care, and telemedicine.24,30,40–44 These interventions may additionally decrease healthcare costs by shifting care from the hospital to home.45,46

In this study, we examine the incidence of outpatient follow-up care after ED encounters for AHF in a large population of commercially insured US patients. We also describe patient characteristics associated with obtaining timely outpatient follow-up care after an ED encounter for AHF.

Methods

Study Design and Setting

We conducted a retrospective cohort study of US adult patients who were discharged from the ED between January 1 2012 and June 30 2019. We used deidentified administrative claims data from the Optum Clinformatics® Data Mart Database. This database contains inpatient and outpatient medical claims, with approximately 18 million unique patients annually during the study period. All patients in this population had private commercial insurance, including Medicare Advantage. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for observational studies.47 The data that support the findings of this study are available from the corresponding author upon reasonable request. The institutional review board at the University of Pennsylvania determined that this study was exempt from review.

Selection of Participants

We identified ED encounters with a diagnosis of acute heart failure, using the Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicator algorithm.48 These included ICD-9-CM diagnosis codes prior to October 2015 and ICD-10-CM diagnosis codes after that date (Table S1). This algorithm excludes admissions for elective cardiac procedures as well as obstetrics. We used validated Current Procedure Terminology (CPT) codes to identify ED encounters (Table S2). We limited the cohort to index encounters, defined as ED encounters with no inpatient admission, observation, or ED encounter in the preceding 30 days. The reason for this exclusion was to capture the start of an illness episode. We excluded ED encounters with disposition of inpatient hospital admission, hospital observation, or hospital transfer, as defined by claims for those services. We excluded patients with fewer than 30 days of continuous insurance enrollment prior to the ED encounter. We excluded patients younger than 18 years, patients with missing data for age and sex, and patients who died during the ED encounter. For patients with multiple qualifying encounters during the study period, we included the first. Figure S1 provides further details on cohort selection.

Outcomes

The primary outcome was a claim for an in-person outpatient clinic visit for heart failure after the ED encounter. To define this outcome, we identified the first outpatient clinic visit following the ED encounter with any principal or secondary diagnosis of heart failure. All outpatient provider types were included. We also defined a secondary outcome for in-person outpatient clinic visits regardless of diagnoses listed for that visit.

In addition, we determined whether patients were hospitalized for any cause within 30 days and without an intervening outpatient clinic visit. We defined that event as a competing risk to the primary outcome.49 Although hospitalization does not preclude the patient from eventually seeking outpatient care, it indicates worsening health status that interfered with the opportunity to obtain outpatient care immediately after the ED encounter. For this study, mortality data were not available. To address this limitation, we identified the date of the last medical or pharmacy claim filed by patients, representing the last date that patients were known to be alive (date of last available data). We censored patients as lost to follow-up if this date occurred within 30 days of the ED encounter.

Study Variables

We examined patient and clinical characteristics hypothesized to be associated with the primary outcome. These included demographic characteristics including age, sex, self-reported race/ethnicity, education level, and annual household income. We reviewed healthcare utilization over the preceding 6 months to determine the number of previous outpatient clinic visits and calculated the Elixhauser co-morbidity index, a single score serving as a proxy for readmission risk.50 We also examined key components of the Elixhauser index that we hypothesized to influence the likelihood of a follow-up visit for heart failure, including history of hypertension, valvular heart disease, peripheral vascular disease, pulmonary circulatory disorders (pulmonary hypertension), chronic pulmonary disease, chronic renal disease, diabetes mellitus, and depression. Finally, we determined the level of the evaluation and management (E&M) billing code for the index ED encounter, representing the intensity of care provided to patients.

Analysis

We described the patient cohort, stratified by the three possible outcomes after the index ED visit for AHF: 1) outpatient clinic visit for heart failure (main outcome); 2) hospitalization prior to outpatient clinic visit (competing outcome); and 3) no outpatient clinic visits for heart failure or hospitalization. Then, we calculated the cumulative incidence of these outcomes within 30 days of the index ED encounter, censored by date of last available data. Current guidelines do not specify the time window in which outpatient follow-up for heart failure after ED visits should occur.15 Therefore, the cumulative incidence function describes outcomes over the entire follow-up period. Below, we highlight outcomes for 7 days as well as 30 days, given that: 1) guidelines recommend 7-day follow-up for patients after inpatient hospital discharge; 2) early follow-up is associated with improved outcomes following hospital discharge, and 3) complex patients who are discharged from the ED are often expected to follow up within 7 days.16,17,22

To determine the association between the outcomes and patient characteristics, we estimated multivariable competing risk regression models.49 This model functions similarly to the Cox proportional hazards model but estimates cause-specific hazards for the main outcome of interest and the competing outcome. This approach was used to account for potentially differential rates in hospitalization between patient groups that may introduce bias. The competing risk regression models are adjusted for the key patient and clinical characteristics described above. As a sensitivity analysis, we fit a Cox proportional hazards model that did not account for competing risks. We used Schoenfeld residuals to test for violations of the proportionality assumption for individual covariates and planned a sensitivity analysis that included non-proportional covariates as time-varying covariates.51,52 All analyses were performed using Stata software, version 16.1 (StataCorp).

Results

The cohort consisted of 52732 patients discharged following an ED encounter for heart failure between January 1 2012 and June 30 2019. The mean age was 73.9 years (SD 12.1), and there were 27395 (52.0%) female patients. 31766 (60.2%) patients reported Non-Hispanic White race, 8514 (16.2%) reported Non-Hispanic Black race, and 4319 (8.2%) reported Hispanic ethnicity. The most common observed co-morbidities included hypertension (33793 (64.1%)), diabetes mellitus (17490 (33.2%)), and chronic renal disease (9010 (17.1%)). Table 1 describes additional patient characteristics.

Table 1.

Characteristics of patients discharged after an emergency department encounter for acute heart failure

Patient Characteristics All patients
N = 52732
No. (%)		 Hospitalization within 30d, prior to outpatient visit
N = 8382
No. (%)		 Outpatient visit for heart failure within 30d
N = 12279
No. (%)		 No outpatient visits for heart failure or hospitalization within 30d
N = 32071
No. (%)
Age (years), mean (SD) 73.9 (12.1) 74.3 (12.2) 74.8 (12.0) 73.4 (12.0)
Sex Male 25337 (48.0) 4103 (49.0) 6387 (52.0) 14847 (46.3)
Female 27395 (52.0) 4279 (51.0) 5892 (48.0) 17224 (53.7)
Race/Ethnicity Non-Hispanic White 31766 (60.2) 4842 (57.8) 7602 (62.0) 19322 (60.3)
Non-Hispanic Black 8514 (16.2) 1387 (16.6) 1680 (13.6) 5447 (17.0)
Hispanic 4319 (8.2) 734 (8.8) 981 (8.0) 2604 (8.1)
Asian 786 (1.5) 133 (1.6) 213 (1.7) 440 (1.4)
Unknown 7347 (13.9) 1286 (15.3) 1803 (14.7) 4258 (13.3)
Education level High school diploma or less 18843 (35.7) 3066 (36.6) 3962 (32.3) 11815 (36.8)
Some college 23725 (45.0) 3564 (42.5) 5811 (47.3) 14350 (44.7)
Bachelor’s degree or more 3897 (7.4) 641 (7.7) 986 (8.0) 2270 (7.1)
Unknown 6267 (11.9) 1111 (13.3) 1520 (12.4) 3636 (11.3)
Annual household income (dollars) Less than $40K 17331 (32.9) 2802 (33.4) 3740 (30.5) 10789 (33.6)
$40K – $74K 12085 (22.9) 1833 (21.9) 3034 (24.7) 7218 (22.5)
$75K - $99K 4789 (9.1) 728 (8.7) 1268 (10.3) 2793 (8.7)
Greater than $100K 4678 (8.9) 702 (8.4) 1253 (10.2) 2723 (8.5)
Unknown 13849 (26.3) 2317 (27.6) 2984 (24.3) 8548 (26.7)
Billing level (intensity) of ED encounter Level 1 or 2 1088 (2.1) 107 (1.3) 119 (0.1) 862 (2.7)
Level 3 5416 (10.3) 596 (7.1) 758 (6.2) 4062 (12.7)
Level 4 13344 (25.3) 1830 (21.8) 2506 (20.4) 9008 (28.1)
Level 5 32884 (62.4) 5849 (69.8) 8896 (72.5) 18139 (56.6)
Outpatient clinic visits in past 6 months None 7597 (14.4) 1317 (15.7) 1195 (9.7) 5085 (15.9)
1 5936 (11.3) 942 (11.2) 1201 (9.8) 3793 (11.8)
2 5829 (11.1) 865 (10.3) 1285 (10.5) 3679 (11.5)
3 or more 33370 (63.3) 5258 (62.7) 8598 (70.0) 19514 (60.9)
Elixhauser comorbidity index, mean (SD) 17.4 (17.6) 19.7 (19.7) 17.6 (17.5) 16.8 (17.1)
Valvular disease 6852 (13.0) 1157 (13.8) 2083 (17.0) 3612 (11.3)
Pulmonary circulatory disorder 1879 (3.6) 396 (4.7) 528 (4.3) 955 (3.0)
Chronic renal disease 9010 (17.1) 1709 (20.4) 2245 (18.3) 5056 (15.8)
Peripheral vascular disease 5910 (11.2) 1059 (12.6) 1412 (11.5) 3439 (10.7)
Hypertension 33793 (64.1) 5256 (62.7) 7872 (64.1) 20665 (64.4)
Diabetes mellitus 17490 (33.2) 2954 (35.2) 3871 (31.5) 10665 (33.3)
Chronic pulmonary disease 8707 (16.5) 1556 (18.6) 1717 (14.0) 5434 (16.9)
Depression 4659 (8.8) 787 (9.4) 951 (7.7) 2921 (9.1)
Year of ED encounter 2012 7396 (14.0) 1171 (14.0) 1554 (12.7) 4671 (14.6)
2013 5699 (10.8) 901 (10.8) 1216 (9.9) 3582 (11.2)
2014 5595 (10.6) 845 (10.1) 1294 (10.5) 3456 (10.8)
2015 5849 (11.1) 899 (10.7) 1297 (10.6) 3653 (11.4)
2016 8241 (15.6) 1351 (16.1) 1817 (14.8) 5073 (15.8)
2017 8317 (15.8) 1389 (16.6) 1998 (16.3) 4930 (15.4)
2018 8071 (15.3) 1250 (14.9) 2089 (17.0) 4732 (14.8)
2019 Q1–Q2 3564 (6.8) 576 (6.9) 1014 (8.3) 1974 (6.2)
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Non-standard abbreviations and acronyms

ED, emergency department

SD, standard deviation

30d, 30 days

Q, quarter

Within 7 days of the ED encounter, 6564 (12.5%) patients attended an outpatient clinic visit for heart failure (Figure 1). An additional 4851 (9.2%) patients were hospitalized within 7 days and before they obtained an outpatient clinic visit. At 30 days, 12279 (23.2%) patients had attended an outpatient clinic visit for heart failure without an intervening hospitalization, and there were 8382 (15.9%) patients who were hospitalized before they obtained an outpatient clinic visit. Of these hospitalizations, 5568 (66.4%) included a diagnosis of heart failure. 1665 (3.2%) patients were lost to follow-up prior to 30 days. Of patients with an outpatient clinic visit for heart failure, 4016 (32.7%) patients were seen by cardiology providers, 3708 (30.2%) by family medicine providers, and 2899 (23.6%) by internal medicine providers. The median time to outpatient clinic visit for heart failure was 8 days (IQR 4 – 16).

Figure 1.

Figure 1

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Outcomes and utilization of outpatient care following emergency department encounter for acute heart failure

Non-standard abbreviations and acronyms

AHF, acute heart failure

There were 20516 (38.9%) patients with outpatient clinic visits regardless of diagnosis within 7 days of the ED encounter. At 30 days, 35261 (66.9%) patients attended any outpatient clinic visit and without an intervening hospitalization. The median time to any outpatient follow-up visit was 7 days (IQR 3 – 13).

Figure 2 plots cumulative incidence functions for the main outcome and competing outcome. In the adjusted analysis, several patient characteristics were significantly associated with obtaining outpatient follow-up after ED discharge (Table 2). A ten-year increase in age increased the relative incidence of outpatient follow-up by 4% (HR 1.04; 95%CI 1.03 – 1.06). Women were less likely (HR 0.84; 95%CI 0.81 – 0.87) to obtain follow-up as compared to men. Patients reporting non-Hispanic Black race were also less likely (HR 0.89; 95% CI 0.84 – 0.94) to obtain follow-up as compared to patients reporting non-Hispanic White race. Patients with relatively lower educational attainment and annual household income were also less likely to obtain outpatient follow-up. Cumulative incidence functions are plotted in Figure 3 for selected patient characteristics, showing absolute differences between groups.

Figure 2.

Figure 2

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Cumulative incidence functions for 1) obtaining outpatient follow-up visit for acute heart failure after ED discharge (main outcome, blue line), and 2) return hospitalization prior to obtaining outpatient follow-up visit for acute heart failure (competing outcome, orange line)

Table 2.

Patient characteristics with cause-specific hazard ratios for 1) obtaining an outpatient follow-up visit for heart failure within 30 days of emergency department discharge (main outcome) and 2) hospitalization prior to obtaining an outpatient follow-up visit (competing outcome)

Patient characteristics Cause-Specific Hazard Ratio (95%CI)
Outpatient Clinic Visit
(Main Outcome)		 P Hospitalization Prior to Clinic Visit
(Competing Outcome)		 P
Age (tens of years) 1.04 (1.03 – 1.06) < 0.001 1.06 (1.03 – 1.07) < 0.001
Sex Male reference -- reference --
Female 0.84 (0.81 – 0.87) < 0.001 0.95 (0.91 – 0.99) 0.02
Race/Ethnicity Non-Hispanic White reference -- reference --
Non-Hispanic Black 0.89 (0.84 – 0.94) < 0.001 1.06 (1.00 – 1.13) 0.05
Hispanic 0.95 (0.89 – 1.01) 0.12 1.06 (0.98 – 1.14) 0.18
Asian 1.12 (0.98 – 1.28) 0.11 1.09 (0.92 – 1.29) 0.33
Unknown 1.07 (0.96 – 1.19) 0.22 1.05 (0.92 – 1.20) 0.44
Education level High school 0.92 (0.89 – 0.96) < 0.001 1.08 (1.02 – 1.14) 0.004
Some college reference -- reference --
Bachelor’s or more 0.94 (0.88 – 1.020 0.13 1.10 (1.01 – 1.20) 0.04
Unknown 1.00 (0.88 – 1.13) 0.95 1.11 (0.95 – 1.29) 0.18
Annual household income (dollars) Less than $40K 0.92 (0.88 – 0.97) 0.002 1.07 (1.01 – 1.13) 0.03
$40K – $74K reference -- reference --
$75K – $99K 0.99 (0.92 – 1.05) 0.69 1.01 (0.93 – 1.10) 0.79
Greater than $100K 0.98 (0.92 – 1.05) 0.65 0.98 (0.90 – 1.08) 0.73
Unknown 0.93 (0.87 – 1.00) 0.11 1.05 (0.98 – 1.13) 0.19
Billing level (intensity) of ED encounter Level 1 or 2 0.56 (0.47 – 0.68) < 0.001 0.70 (0.57 – 0.84) < 0.001
Level 3 0.72 (0.66 – 0.78) < 0.001 0.79 (0.72 – 0.87) < 0.001
Level 4 reference -- reference --
Level 5 1.50 (1.43 – 1.56) < 0.001 1.33 (1.26 – 1.40) < 0.001
Outpatient clinic visits in previous 6 months None reference -- reference --
1 1.27 (1.17 – 1.38) < 0.001 0.90 (0.82 – 0.97) 0.009
2 1.38 (1.28 – 1.49) < 0.001 0.83 (0.76 – 0.90) < 0.001
3 or more 1.61 (1.51 – 1.72) < 0.001 0.85 (0.80 – 0.91) < 0.001
Valvular disease 1.33 (1.26 – 1.39) < 0.001 1.05 (0.98 – 1.12) 0.16
Pulmonary circulatory disorder 1.18 (1.08 – 1.29) < 0.001 1.33 (1.20 – 1.47) < 0.001
Chronic renal disease 1.06 (0.99 – 1.11) 0.05 1.23 (1.16 – 1.30) < 0.001
Hypertension 1.01 (0.97 – 1.06) 0.57 0.83 (0.79 – 0.87) < 0.001
Peripheral vascular disease 0.96 (0.91 – 1.02) 0.21 1.09 (1.03 – 1.17) 0.009
Diabetes mellitus 0.92 (0.88 – 0.96) < 0.001 1.11 (1.06 – 1.16) .0.001
Depression 0.88 (0.83 – 0.94) < 0.001 1.08 (1.00 – 1.170 0.04
Chronic pulmonary disease 0.78 (0.74 – 0.82) < 0.001 1.13 (1.07 – 1.19) < 0.001
Year of ED visit 2012 reference reference --
2013 0.99 (0.92 – 1.07) 0.88 1.01 (0.93 – 1.10) 0.77
2014 1.08 (1.00 – 1.16) 0.05 0.96 (0.88 – 1.05) 0.37
2015 1.03 (0.96 – 1.11) 0.44 0.97 (0.89 – 1.06) 0.45
2016 1.09 (1.02 – 1.17) 0.01 1.04 (0.96 – 1.13) 0.32
2017 1.14 (1.07 – 1.22) < 0.001 1.05 (0.97 – 1.14) 0.22
2018 1.22 (1.15 – 1.31) < 0.001 0.96 (0.88 – 1.04) 0.31
2019 Q1–Q2 1.36 (1.25 – 1.47) < 0.001 0.99 (0.90 – 1.10) 0.89
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Non-standard abbreviations and acronyms

ED, emergency department

CI, confidence interval

Q, quarter

Figure 3.

Figure 3

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Cumulative incidence functions for obtaining outpatient follow-up visit, by select patient characteristics, clockwise from top left: age; sex; household income; year of ED encounter; clinic visits within past 6 months; self-reported race/ethnicity

Non-standard abbreviations and acronyms

ED, emergency department

Patients with outpatient clinic visits for heart failure within the preceding 6 months had higher likelihood of obtaining outpatient follow-up; patients with 3 or more recent visits had 61% greater incidence as compared to patients with none (HR 1.61; 95%CI 1.51 – 1.72). Patients with known valvular disease (HR 1.33; 95%CI 1.26 – 1.39) or pulmonary hypertension (HR 1.18; 95%CI 1.08 – 1.29) were more likely to obtain outpatient follow-up. However, patients with three co-morbidities were less likely to obtain outpatient follow-up for heart failure: chronic pulmonary disease (HR 0.78; 95%CI 0.74 – 0.82), depression (HR 0.88; 95%CI 0.83 – 0.94), and diabetes mellitus (HR 0.92; 95%CI 0.88 – 0.96).

The level of billing code for the index ED encounter demonstrated a stepwise increase in likelihood of obtaining an outpatient follow-up visit. Patients who had ED encounters with the highest billing level (Level 5) were significantly more likely (HR 1.50; 95%CI 1.43 – 1.56) than patients with Level 4 codes. Finally, the likelihood of obtaining follow-up increased over time; patients with ED encounters in 2019 were significantly more likely (HR 1.36; 95%CI 1.25 – 1.47) than those in 2012.

For analysis of the secondary outcome, association remained significant with the exception of age, history of chronic pulmonary disease, history of pulmonary hypertension, and history of diabetes mellitus (Table S3, Figure S2). In addition, patients with history of hypertension had a small yet significant increase in likelihood of obtaining an outpatient clinic visit (HR 1.06; 95%CI 1.03 – 1.08). The main sensitivity analyses demonstrated generally equivalent results to the main analyses (Table S4, Figure S3. Finally, we determined that age, non-Hispanic Black race, history of pulmonary hypertension, history of chronic renal disease, and history of chronic pulmonary disease failed tests for proportionality assumptions in the main model. However, plots of Schoenfeld residuals demonstrated very minor change in hazards over time, and inclusion of these characteristics as time-varying covariates had little effect on the results (Figure S4).

Discussion

In this study, we found that only 1 in 8 patients who are evaluated, treated, and discharged from the ED for acute heart failure attend outpatient follow-up visits within 7 days. At 30 days, 1 in 4 patients obtain follow-up. As compared to hospital admission, ED evaluations may not include specialty consultation, advanced diagnostic testing, and importantly, time to observe symptom progression and the effects of treatment. An outpatient encounter allows clinicians to reevaluate symptoms, adjust medications, reinforce self-care strategies, and order further testing – all of which are time-sensitive actions for patients who recently sought emergency care. Given the high rate of complications for AHF patients after ED visits, these encounters should signal an opportunity to engage patients and prevent further illness progression.

Our main findings differ from the limited existing literature that describes outcomes among AHF patients following ED discharge. One study of over 7000 patients found that 75 percent of patients obtained some type of follow-up care, including outpatient clinic visits as well as telephone and email communication, within 7 days.10 However, the study was conducted in an integrated healthcare system with care coordination services that are not available to the general US population. Canadian studies have also found high rates of follow-up; one study demonstrated that 65 percent of patients discharged from the ED obtained outpatient follow-up within 14 days, generally with clinicians who had previously cared for the patient.19,31 We examined whether patients had any outpatient clinic visits following the ED encounter – regardless of whether the diagnosis of heart failure was assigned to the outpatient encounter. While the rate of follow-up at 7 days increased to 39%, the reason for those visits may not have been related to the illness prompting the ED encounter.

In this study, nearly 20% of patients returned to the hospital for admission within 30 days. This rate is similar to the 30-day readmission rate for patients who are discharged following hospitalization.53 Previous studies have described the risk of adverse outcomes, including mortality and return hospital admission, for AHF patients following ED discharge. In two studies, the mortality rate within 7 days was 1.3% and 1.2%.8,10 In addition, a secondary analysis of a large Spanish cohort of ED patients with heart failure found that nearly 30% of patients discharged directly from the ED returned within 30 days.54 It is unclear whether patients discharged from the ED who experience adverse outcomes might have benefited from hospitalization during their initial presentation. Several notable studies have sought to risk stratify AHF ED patients and identify those at high-risk for short-term adverse outcomes.34–37 However, these derivation studies included patients discharged from the ED as well as those who received hospitalization, therefore not accounting for the modifying effect of care delivered during hospital admission.6,33 In addition, risk stratification scores only include patient variables present at the time of ED disposition and do not consider whether – and how quickly – patients obtain follow-up.6 Currently, no risk stratification tools have been widely adopted to guide disposition of ED patients with heart failure.7,26

Importantly, it is unclear whether timely outpatient follow-up care improves outcomes for AHF patients discharged from the ED. Many confounders make this question challenging to answer using observational study designs.25,28,31 For example, patients may be more likely to seek outpatient care if their symptoms worsen rather than improve, leading to greater adverse outcomes among patients who obtain outpatient care. Conversely, patients with severe symptoms may be less able to attend an outpatient clinic visit, resulting in more adverse outcomes among patients who do not obtain outpatient care. No randomized trials have attempted to answer this question, to our knowledge. A recent notable study randomized AHF patients to receive home visits and self-care interventions following ED discharge, demonstrating improvement in a composite rank outcome at 30 days but not the primary outcome of 90 days.24,30 However, patients in both study arms received an outpatient appointment with a heart failure clinician within 7 days of ED discharge. The paucity of literature in this population is notable considering the many studies conducted among patients discharged following an inpatient hospital admission for heart failure.20 Further validation of existing risk scores among populations who do and do not obtain follow-up may provide insight into the benefits of outpatient follow-up care. In addition, future studies may also seek to evaluate alternatives to traditional outpatient clinic visits to monitor patients, including telemedicine, home health interventions, and remote monitoring.21,40–42

Another unanswered question is whether improved clinical care pathways that ensure timely outpatient care can alter disposition decisions for ED patients with AHF.5 Several alternatives to hospital admission have been studied and adopted, including the use of observation units, hospital at home programs, and dedicated care transition clinics.6,55,56 Improved care navigation and monitoring might, in some cases, allow ED providers and patients to opt for outpatient management rather than hospitalization.

This study found that specific populations had lower adjusted rates of outpatient follow-up, including women, Black patients, and younger patients with heart failure. Given that all patients in this cohort were commercially insured, these differences should not be attributed to barriers related to insurance coverage. Overall, the absolute differences between these groups were small. One exception is recent use of outpatient care; patients with 3 or more outpatient visits in the preceding 6 months had nearly twice the rate of follow-up compared to those with none. This difference may reflect the challenges of establishing or re-establishing care for patients who are not actively engaged in outpatient care, which is particularly problematic for high-risk chronic conditions like heart failure. It may provide another reason why AHF patients are rarely discharged from the ED even if their hospital stay is expected to be brief. Another notable finding were the increased rates of follow-up care in 2019 as compared to 2012, possibly reflecting overall increased access to outpatient care since passage of the Affordable Care Act or spillover effects from policies and interventions to improve care transitions after hospital admission.57,58

This study has several limitations. First, this study uses administrative claims data which relies on diagnosis codes to identify patients with heart failure. This approach likely misses some ED encounters for heart failure while incorrectly attributing others. It is also possible that some outpatient follow-up visits were not assigned the diagnosis of heart failure. The secondary outcome was included for this reason, establishing an upper bound for the true incidence of outpatient follow-up. Second, claims data do not measure severity of symptoms or illness. While patients with severe illness were generally likely to have been hospitalized and therefore excluded from this study, symptom burden may be an important consideration in determining who obtains – and who benefits – from outpatient care. Furthermore, this study did not distinguish between classes or types of heart failure, including data on ejection fraction. Third, we lacked mortality data. Instead, we censored patients based on the date of last lifetime claim, as a marker for last known date alive. Fourth, this study does not examine alternatives to traditional outpatient clinic visits, including telemedicine follow-up encounters. Fifth, this study does not include patient characteristics which may influence attendance of clinic visits, such as transportation access. In addition, we are unable to characterize, due to the nature of claims data, the reasons for whether patients did or did not obtain appointments. Finally, this study only includes patients with private commercial insurance or Medicare Advantage and may not be generalized to other populations including those with traditional Medicare, Medicaid, or no insurance, although the rate of timely follow-up care may be expected to be even lower for those populations.

In summary, we found that few patients obtain outpatient follow-up visits after seeking emergency care for heart failure, despite an overall rate of hospitalization of nearly 20% within 30 days of the index ED encounter. Efforts to improve care transitions for heart failure patients discharged from the ED may not only improve outcomes but also create alternative strategies to hospitalization for the large proportion of ED patients with heart failure who are admitted each year. Future studies may seek to determine whether timely outpatient follow-up care improves outcomes for ED patients with heart failure or whether additional monitoring or interventions are also needed.

Supplementary Material

Supplemental Materials
Supplemental Publication Material

What is Known and What the Study Adds.

What is Known

  • Some patients who visit the emergency department (ED) for decompensated heart failure may be stabilized and discharged without hospitalization, although these patients are at high risk for adverse outcomes

  • Early outpatient follow-up care is associated with improved outcomes following hospital admission for heart failure, but this association is less certain following discharge from the ED

  • Clinical care pathways and other interventions that support patients following hospital discharge generally do not include patients discharged from EDs

What the Study Adds

  • This study is the first to characterize the incidence and timing of outpatient clinic follow-up visits after ED encounters for heart failure in a large, national cohort patients in the US

  • Only 1 in 8 patients obtain outpatient clinic follow-up visits within 7 days of discharge after an ED encounter for heart failure, with noted disparities based on sex, race, and previous use of outpatient care

Sources of Funding

Research reported in this publication was supported by a pilot grant from the Leonard Davis Institute of Health Economics (Wharton School, University of Pennsylvania, Philadelphia Pennsylvania). Dr. Kilaru was supported by the Agency for Healthcare Research and Quality under award number (5K12HS026372-04). Dr. Merchant was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) under award number K24-HL157621. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Non-Standard Abbreviations and Acronyms

ED

emergency department

AHF

acute heart failure

STROBE

Strengthening the Reporting of Observational Studies in Epidemiology

AHRQ

Agency for Healthcare Research and Quality

ICD-9-CM

International Classification of Diseases, Ninth Revision, Clinical Modification

ICD-10-CM

International Classification of Diseases, Tenth Revision, Clinical Modification

CPT

Current Procedure Terminology

E&M

evaluation and management billing codes

HR

hazard ratio

CI

confidence interval

Footnotes

Disclosures

None

Supplemental Materials

Supplemental Methods (Table S1–S2, Figure S1)

Tables S3 – S4

Figures S2 – S4

Contributor Information

Austin S. Kilaru, Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania; Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania.

Nicholas Illenberger, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania.

Zachary F. Meisel, Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania; Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania.

Peter W. Groeneveld, Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania.

Manqing Liu, Department of Epidemiology, T.H. Chan School of Public Health, Harvard University.

Angira Mondal, Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania.

Nandita Mitra, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania.

Raina M. Merchant, Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania; Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania.

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Supplementary Materials

Supplemental Materials
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Supplemental Publication Material
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