The Ups and Downs of ED Follow-Up

By Christina Ambrosino

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Case

History of Present Illness

A 39-year-old male with a history of hypertension presents to the ED with a 3-day history of gradually increasing right testicular pain. He has experienced mild dysuria and his baseline level of urinary frequency with 5-10 nightly awakenings. He denies recent fever or chills, and has not noticed any urethral discharge or genital ulcers. He has not taken his home blood pressure medication since the onset of symptoms.

Physical Exam

Vital signs were significant for a blood pressure of 172/90 and a temperature of 98.8 F. On genitourinary exam, the scrotum was erythematous and enlarged with minimal change in pain on elevation of the testicles. Cremasteric reflex was preserved. No crepitus was present. There was no purulent drainage from the urethral meatus and no ulcers or lesions were observed.

Labs and Imaging

CBC was significant for white blood cell elevation of 12.8. 

CMC was significant for a glucose of 246. 

Urinalysis showed 1+ proteinuria and elevated white blood cells to 3,140.

Scrotal doppler ultrasound showed preserved vascular flow to testicles bilaterally. 

Family history

Strong family history of both type II diabetes mellitus and hypertension. 

Social history

Currently sexually active with history of multiple gonorrhea and chlamydial infections. He is unsure whether all infections were treated. 

Works full-time at a demanding job and finds it difficult to take time off from work. 

ED course

In the setting of his testicular pain, leukocytosis, and history of sexually transmitted infections, clinical concern was greatest for epididymitis. Concern was low for testicular torsion and Fournier gangrene given his normal doppler ultrasound with preserved cremasteric reflex and lack of purulence or crepitus on genitourinary exam, respectively.

He was ordered an STI panel, which included gonorrhea and chlamydia tests, and received IM ceftriaxone. Due to his increased blood glucose in the setting of a strong family of diabetes, he was briefly counseled regarding a likely diagnosis of diabetes mellitus. 

He was discharged with prescriptions for both PO levofloxacin, metformin, and a plan to follow-up with both urology and a primary care physician (PCP).

Clinical question: Are patients who are discharged with instructions to follow-up with a PCP or specialty care able to access those services? What can we do to support patients in following-up after ED visits?

Summary of Evidence

Introduction

Many ED encounters require follow-up visits to PCPs or specialty services to ensure adequate resolution, treatment, or management of acute conditions. For example, a follow-up appointment with urology is frequently given for the diagnosis of epididymitis. Similarly, a newfound diagnosis of diabetes generally requires careful titration of medications and patient counseling in order to successfully achieve good glycemic control. 

Existing studies show, however, that many individuals struggle to complete follow-up recommendations following ED encounters, with reports ranging from 16.6% to 73.8% of individuals becoming lost-to-follow-up.1–3

Key barriers

From a study of patients without either insurance or a PCP who were offered a cost-free follow-up visit, 52% of patients were unable to keep or attend their scheduled follow-up.4 When interviewed regarding their barriers to follow-up, patients reported issues such as transportation, forgetting their appointment, perceived cost, and either work or child care commitments.4 Though patients with language barriers may be less likely to be offered a follow-up appointment by providers for similar chief complaints – an issue in itself – existing data suggests that follow-up compliance is similar regardless of whether an interpreter is used.5

Interventions

An interventional study by Messina et al. aimed to increase ED follow-up rates to specialty care services by waiving payment requirements and scheduling follow-up appointments prior to ED discharge.6 In that setting, the majority of patients were able to keep their appointments with only 19.9% of patients lost-to-follow-up overall.6 Across specialties, dermatology and general surgery follow-up appointments were less frequently kept while urology and ophthalmology were the most frequently attended appointments throughout the intervention.6 The process of scheduling follow-up appointments before ED discharge and providing patients a written reminder of their appointments has similarly improved follow-up rates within the pediatric ED setting.7 Interestingly, however, neither text-based appointment reminders, mailed reminders, or instructional videos regarding the importance of follow-up care significantly improved follow-up compliance.3,8

Outside of the ED, patient navigators who assist in addressing social determinants of health have been shown to have a positive impact on compliance to general health appointments in both pediatric9 and adult10 settings. Though limited literature exists regarding the effect of patient navigators on follow-up from the emergency setting in particular, resource connection may be a viable future direction to decrease barriers to ED follow-up care.

Summary and Recommendations

1. Scheduling (or encouraging patients to call and schedule) important follow-up appointments before discharge from the ED may improve follow-up adherence.

2. Efforts to address patients’ barriers to care (eg. cost/insurance, transportation) may be more effective than most reminder-based interventions in increasing ED follow-up compliance; providers may consider prioritizing social work consults or directly engaging in resource connection, as time allows.

Resources

1. Prudhomme N, Kwok ESH, Olejnik L, White S, Thiruganasambandamoorthy V. A Health Records Review of Outpatient Referrals from the Emergency Department. Emerg Med Int. 2019;2019:1-7. doi:10.1155/2019/5179081 2. Vukmir RB, Kremen R, llis GL, Hart DA, lewa MC, Menegazzi J. Compliance with emergency department referral: the effect of computerized discharge instructions. Ann Emerg Med. 1993;22(5):819-823. doi:10.1016/S0196-0644(05)80798-X

3. Salinero EA, Ramirez J, Cramm-Morgan K, Papa L. Does Receiving a Text Message Reminder Increase Follow-up Compliance After Discharge From a Pediatric Emergency Department? Pediatr Emerg Care. 2021;37(9):e507-e511. doi:10.1097/PEC.0000000000001675

4. Naderi S, Barnett B, Hoffman RS, et al. Factors associated with failure to follow-up at a medical clinic after an ED visit. Am J Emerg Med. 2012;30(2):347-351. doi:10.1016/J.AJEM.2010.11.034

5. Sarver J, Baker DW. Effect of Language Barriers on Follow-up Appointments After an Emergency Department Visit. J Gen Intern Med. 2000;15(4):256. doi:10.1111/J.1525-1497.2000.06469.X

6. Messina FC, McDaniel MA, Trammel AC, Ervin DR, Kozak MA, Weaver CS. Improving specialty care follow-up after an ED visit using a unique referral system. Am J Emerg Med. 2013;31(10):1495-1500. doi:10.1016/J.AJEM.2013.08.007

7. Komoroski EMM, Graham CJM, Kirbey RSPM. A comparison of interventions to improve clinic follow-up compliance after a pediatric emergency department visit. Pediatr Emerg Care. 1996;12(2):87-90. Accessed January 25, 2023. https://journals.lww.com/pec-online/Abstract/1996/04000/A_comparison_of_interventions_to_improve_clinic.5.aspx

8. Zorc JJ, Chew A, Allen JL, Shaw K. Beliefs and Barriers to Follow-up After an Emergency Department Asthma Visit: A Randomized Trial. Pediatrics. 2009;124(4):1135-1142. doi:10.1542/PEDS.2008-3352

9. Hill S, Topel K, Li X, Solomon BS. Engagement in a Social Needs Navigation Program and Health Care Utilization in Pediatric Primary Care. Acad Pediatr. 2022;22(7):1221-1227. doi:10.1016/J.ACAP.2022.05.012

10. Leiby BE, Hegarty SE, Zhan T, et al. A Randomized Trial to Improve Adherence to Follow-up Eye Examinations Among People With Glaucoma. Prev Chronic Dis. 2021;18:1-12. doi:10.5888/PCD18.200567