103 Impact of Self-Perceived Risk and Trust in the Emergency Physician on Outpatient Follow-Up in Low-Risk Chest Pain Patients Discharged From the Emergency Department

Abstract

It is appropriate to discharge patients who present to the emergency department (ED) with symptoms consistent with acute coronary syndrome (ACS) with close outpatient follow-up if they are deemed to be low-risk. Patient compliance with follow-up in this population remains a challenge; little is understood about barriers to follow-up beyond associated demographic and social factors. We hypothesize that a patient’s perception of their risk for cardiac disease and their trust in the emergency physician at the time of discharge impact compliance with follow-up in a low-risk for ACS chest pain population. This is a prospective study of patients who presented to a large urban ED with chest pain who were discharged with a scheduled follow-up appointment at an acute response clinic (ARC). ARC appointments are provided to patients regardless of insurance status. All data was collected by in-person surveys administered prior to discharge from the emergency department. Subjects provided demographic information, completed the Short Assessment of Health Literacy (SAHL-E), the Trust in Physician Scale (TiPS), estimated their risk for heart disease, and were asked to report barriers to follow-up. Patients were followed via the electronic medical record to assess whether they attended their ARC appointment. Descriptive statistics were used to calculate differences. 70 patients were enrolled in this study. The average age of the cohort is 48.8 years and it is comprised of 54.3% women with an overall follow-up rate of 42.9%. Five patients cancelled their ARC appointments; 4 of these 5 patients achieved follow-up with an outside clinic, 1 patient was lost to follow-up. Patients who reported low self-perceived risk of heart disease, less than 10%, were less likely to show for their follow-up appointment than those reporting high self-perceived risk, between 10-99% (19% versus 46%, p<0.05). Seven patients reported 100% risk and were excluded from significance testing as they already carried a diagnosis of heart disease. Additionally, low-trust in the emergency physician was associated with a higher follow-up rate as compared with medium and high-trust in the physician (52% versus 27.5%, p<0.05). Sex, age, employment, and insurance status were not associated with follow-up rate. 60% of patients reported having barriers to follow-up; transportation was the most commonly noted barrier (58.9%). Patients who reported barriers to follow-up and patients who screened positive for low health literacy did not have lower follow-up rates. Patient perception of having a low-risk for cardiac disease and a high level of trust in the emergency physician at the time of ED discharge are associated with lower follow-up rates in chest pain patients. Patients may commonly mistake their negative ED work up as proof that they do not have cardiac disease. Research evaluating the impact of informing patients of their calculated risk for cardiac disease, as well as providing patient education about the value of outpatient follow-up on appointment compliance, is needed.