Reducing PED Reattendance Rates

Title 060914

http://www.ncbi.nlm.nih.gov/pubmed/25162691

What is this paper about (what is the research question)?

Can we reduce the number of reattendances to the paediatric emergency department by telephoning within 24h of discharge?

Summary of the Paper

Design: Single-centre, prospective randomised controlled trial

Objective:  to examine whether a follow-up telephone call by a non-health care provider from the ED within 24h of discharge can reduce the rate of returning to the ED within 72h

Outcomes:  rate of return visits within 72h of discharge. It is unclear how this was determined but subjects were contacted by telephone at 96h after discharge in both intervention and control groups.

Intervention: follow-up phone call within 12-24h of discharge undertaken by a “research assistant” (medical student)

Comparison:  standard care (i.e. no follow up phone call)

Participants: convenience sample of parents of patients presenting to a single centre between 1st July 2009 and 30th August 2009.

  • Inclusions: parents of patients for whom the responsible clinician thought ED discharge was likely
  • Exclusions: families without a telephone, those who left without being seen, those leaving against medical advice

Results: 371 subjects were recruited of whom 171 were in the study group and received a follow-up phone call and 200 were in the control group. Demographics were broadly similar between the two groups.

24/171 in the study group reattended within 72h (14%)

14/200 in the control group reattended within 72h (7%)

There was a statistically significant difference between reattendance rates with a greater proportion of reattendances in the intervention group (p<0.03).

Authors’  conclusions

 Emergency Departments practicing follow-up calls without response to medical questions should consider a forecasted increase in return rates

On the study design

This is a single centre pseudo-randomised controlled trial – the authors tell us that it was pseudo-randomised because there were research staff available to recruit at different hours of the day. It’s not clear exactly how this statement refers to randomisation but if the time of day patients presented to the ED predicted whether they entered the intervention or control group then there’s potentially a major confounder in the first premise of the paper.

Inclusion and exclusion criteria seem reasonable but the demographics of the subjects throws up some interesting issues; the mean age of the presenting child was 5.7years with a mean parental age of 38.3 years. I can’t help but wonder whether a similar study in my own department would reveal a rather different (substantially younger) parental population and there are sociological implications to this.

There is no sample size calculation so although there were reasonable numbers in each group we don’t know whether the study was fundamentally underpowered and unable to detect a statistical difference between groups. Whether this statistical difference represents a clinically relevant outcome measure is also in question (and addressed below).

What were the results and what does this mean?

On the surface it seems that telephone follow-up within 12-24 hours of ED discharge increases rather than decreases reattendance rates, but the picture is rather more complicated.

Firstly, there is an intrinsic uncertainty surrounding the value of follow-up calls by non-healthcare professionals. Of particular note, the telephone interviews were undertaken by medical students. It seems that conversations were one-way; parents were asked whether they had any questions but there was no opportunity for them to be answered. It seems possible that introducing the concept that there might be unanswered questions could actualise occult parental anxiety, prompting them to seek clarification from a healthcare professional.

Secondly, it’s not even clear how reattendance data was obtained. Was this self-reported by parents at the 96h phone call? It seems so – in which case it could almost certainly have been collected more reliably using ED computerised records.

Thirdly, all manner of data about these reattending subjects is omitted. Were they actually unwell and then admitted to the hospital? Were all reattenders in both groups discharged from  ED again? Without this information it is difficult to ascertain whether reattendance was inappropriate.

What can we take from this paper into clinical practice?

Follow-up phone calls by non-healthcare professionals do not seem to reduce reattendances. However it’s unlikely that this model would ever be rolled out and there are plenty of other questions we still need answers to.

More questions to ask

  • Are these effects the same in an adequately powered study where outcomes are divided into admission or discharge at reattendance (arguably more clinical relevant)?
  • Would attendances be reduced if phone calls were made by healthcare professionals and provided an opportunity to obtain advice and have questions answered?

 

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