Post-discharge early follow-up clinics

National Guideline Centre (UK)

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National Guideline Centre (UK). Emergency and acute medical care in over 16s: service delivery and organisation. London: National Institute for Health and Care Excellence (NICE); 2018 Mar. (NICE Guideline, No. 94.)

Emergency and acute medical care in over 16s: service delivery and organisation.

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Chapter 37Post-discharge early follow-up clinics

37. Post-discharge early follow-up clinics

37.1. Introduction

Timely outpatient follow-up has been promoted as a strategy to reduce hospital readmissions and obtain better longer term health outcomes for patients. It is understood that there are a number of acute medical emergency conditions where the days immediately following discharge are a vulnerable period. Often in such conditions care is complicated and co-ordination of care is important in preventing readmission. Frequently in such conditions there are often additions or changes in therapy that may have unknown or unpredictable effects especially when patients have other co-morbidities. Early review therefore would seem a logical strategy to consider.

Early readmission to hospitals including readmission within 30 days of discharge in the acute medical emergency population is responsible for a large proportion of healthcare spend. It is therefore of interest to understand if early follow-ups in either all or particular specialties would be clinically beneficial and cost-effective to patient management. Furthermore, it would be useful to understand if the early follow up clinics should by be conducted by primary care physicians, hospital physicians or in a multidisciplinary team.

37.2. Review question: Do post discharge early follow up clinics optimise outcomes for patients with a suspected or confirmed acute medical emergency?

For full details see review protocol in Appendix A.

Table 1

PICO characteristics of review question.

37.3. Clinical evidence

Nine studies (10 papers) were included in the review;⁴^,⁷^–¹⁰^,¹⁵^–¹⁷^,²⁵^,²⁶ these are summarised in Table 2 below. Evidence from these studies is summarised in the clinical evidence summary below (Table 3). See also the study selection flow chart in Appendix B, forest plots in Appendix C, study evidence tables in Appendix D, GRADE tables in Appendix F and excluded studies list in Appendix G.

Table 2

Summary of studies included in the review.

Table 3

Clinical evidence summary: follow up clinic versus no follow up clinic.

37.4. Economic evidence

Published literature

One health economic study were identified with the relevant comparison and was included in this review.⁷ This is summarised in the economic evidence profile below (Table 4) and the economic evidence table is in Appendix E.

Table 4

Economic evidence profile: Follow up clinic versus no follow up clinic.

The economic article selection protocol and flow chart for the whole guideline can found in the guideline’s Appendix 41A and Appendix 41B.

37.5. Evidence statements

Clinical

Nine studies comprising 3271 people evaluated the role of post discharge early follow up clinics for improving outcomes in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that post discharge early follow up clinics may provide a benefit in reduced mortality in heart failure patients (8 studies, low quality), quality of life (1 study, very low quality), readmission for heart failure patients readmitted for any cause (2 studies, low quality) and readmission due to heart failure (5 studies, very low quality). However, the evidence suggested there was no effect on mortality in general medical patients (1 study, moderate quality), avoidable adverse events expressed as urgent transplantation (1 study, very low quality), ED attendance (1 study, low quality) and readmission in general medical patients (2 studies, low quality).

Economic

One cost-consequences analysis showed that post discharge follow up clinics were cost saving and resulted in improved health outcomes including reduced mortality and reduced re-admissions. This analysis was assessed as partially applicable with potentially serious limitations.

37.6. Recommendations and link to evidence

Recommendations	-
Research recommendations	RR16. What is the clinical and cost effectiveness of post-discharge early follow up clinics for people who have had a medical emergency and are at risk of unscheduled hospital readmission?
Relative values of different outcomes	The guideline committee considered mortality, avoidable adverse events, quality of life, patient satisfaction, ED attendance and return to work to be critical outcomes. Carer satisfaction/burden and readmission were considered to be important outcomes.
Trade-off between benefits and harms	A total of 9 studies were identified that assessed post discharge early follow up clinics. Eight of these were in heart failure patients and 1 study included general medical patients. Heart failure patients The evidence suggested that post discharge early follow up clinics may provide a benefit for heart failure patients in reduced mortality, quality of life, readmission for heart failure (reported from 3-12 months) and readmission for any cause (at 6-12 months). However, the evidence suggested there was no effect on avoidable adverse events (urgent transplantation). General medical patients There was no effect on mortality, ED attendance and readmission at 12 months for patients discharged from a general internal medical medicine ward. No evidence was identified for patient satisfaction, readmission within 30 days, return to work or carer satisfaction/burden. Eight of the 9 studies included in the review were based on the heart failure population. The committee considered that this evidence could not be generalised to unselected patients with acute medical emergencies. Therefore, the committee did not consider there to be enough evidence to support a general recommendation. The NICE guideline on acute heart failure in adults recommends that a follow-up clinical assessment should be undertaken by a member of the specialist heart failure team within 2 weeks of the person being discharged from hospital.²⁰ The committee emphasised the challenges inherent in evaluating people with multimorbidity. It was also noted that in patients with unselected medical conditions, the requirement and the timing of follow up, if required at all, may vary considerably between each presenting or admitting condition. The committee agreed that a research recommendation on post discharge early follow up clinics was appropriate to ascertain if they had a role in the management of patients presenting with acute medical emergencies.
Trade-off between net effects and costs	One of the studies included in the review included a cost analysis that was suitable for inclusion as economic evidence. It was in a heart failure population and showed cost savings as well as reduced mortality and readmission for the follow up clinic intervention. Another study found similar cost savings also in a heart failure population but was outside the time period for studies included in the review. The committee found the heart failure evidence compelling and were content to cross-refer to the relevant recommendation from NICE’s Acute Heart Failure guideline but did not feel they could make a recommendation generalisable to all acute medical conditions, as the evidence was limited to that population.
Quality of evidence	Evidence for the outcome of mortality was considered to be a mixture of moderate quality due to indirectness and low quality due to risk of bias and indirectness (of study intervention). For avoidable adverse events, evidence was considered to be of very low quality due to risk of bias, indirectness (of study intervention) and imprecision. Evidence for ED attendance was considered to be of low quality due to risk of bias and indirectness (of study intervention). Evidence for quality of life was considered to be of very low quality due to risk of bias, indirectness (of study intervention) and imprecision. For readmission in general medical patients, the evidence was considered to be moderate quality due to indirectness. Readmission in heart failure patients readmitted for any cause was low quality due to risk of bias and indirectness (of study intervention) and readmission due to heart failure evidence was very low quality due to risk of bias, inconsistency, indirectness (of study intervention) and imprecision. The included economic evaluation was assessed as partially applicable because it was not from a UK NHS perspective and because it did not use QALYs as an outcome measure. It was assessed as having potentially serious limitations because it was based on a single trial that may not reflect the entire evidence base.
Other considerations	Heart failure clinics are already part of current clinical practice. Heart failure is associated with a large burden on the NHS. It accounts for 2% of the NHS budget much of which is due to inpatient care.¹⁹ Patients with heart failure are at a high risk of readmission. People with other chronic conditions such as chronic obstructive pulmonary disease were also identified by the committee as being at a high risk of readmission. Targeting such conditions with early follow up may be beneficial in preventing readmission. There are many tools available for identifying patients who are at high risk of readmission. The committee considered that conducting early follow up may complement interventions that promote timely discharge. However, defining precisely the timing and content of the intervention (for example, staff, interval or setting) are critical for interpreting research outcomes. Currently with respect to post discharge clinics, this information is not well characterised. Access to such clinics for patients would be important, particularly for the frail elderly. Provision of such services in the community would need to be considered. Also, the impact of such clinics on other outpatient or GP clinics would need to be examined. Patients who require specialised evaluation as part of their follow up, particularly in terms of equipment which is not portable, may benefit from such an approach but these patients need to be defined. Patients with specific chronic diseases would likely be followed up by the relevant speciality; those with multimorbidity require an integrated approach to improve outcomes, including patient convenience and satisfaction and minimising duplication of effort. The cost of delivering these services must also be taken into account and this is likely to be a major driver in the decision making of where to place services.

References

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Appendices

Appendix A. Review protocol

Table 5Review protocol: post discharge early follow up clinics

Review question	Do post discharge early follow up clinics optimise outcomes for patients with a suspected or confirmed acute medical emergency?
Guideline condition and its definition	Acute medical emergencies.
Review population	Adults and young people (16 years and over) with a suspected or confirmed AME.
	Adults.
	Line of therapy not an inclusion criterion.
Interventions and comparators: generic/class; specific/drug (All interventions will be compared with each other, unless otherwise stated)	Attendance at a post discharge follow up clinic; including attending a post critical/critical illness clinic. Attendance at a post discharge follow up clinic; post discharge clinic. Attendance at a post discharge follow up clinic; early follow up clinic. No post discharge or early follow up clinic; as defined by study.
Outcomes	- Quality of life (Continuous) CRITICAL - Mortality (Dichotomous) CRITICAL - Avoidable adverse effects (Dichotomous) CRITICAL - Readmission up to 30 days (Dichotomous) IMPORTANT - Patient and/or carer satisfaction (Dichotomous) CRITICAL - Return to work (Dichotomous) CRITICAL - ED Attendance (Dichotomous) CRITICAL - Carer satisfaction/burden (Dichotomous) IMPORTANT
Study design	Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified.
Unit of randomisation	Patient. Hospital. Ward.
Crossover study	Not permitted.
Minimum duration of study	Not defined.
Other exclusions	Community rehabilitation. Hospital at home. Community matron. Home visits.
Subgroup analyses if there is heterogeneity	- Frail Elderly (frail elderly; no frail elderly); different outcomes for frail. - Critical illness (critically ill; not critically ill); different outcome for critically ill patients. - Clinic within 7 days of discharge (within 7 days; not within 7 days); different outcome for clinic within 7 days. - Clinic within 28 days of discharge (within 28 days; not within 28 days); different outcome for clinic within 28 days.
Search criteria	Databases: Medline, Embase, the Cochrane Library. Date limits for search: None. Language: English.

Appendix B. Clinical article selection

Figure 1Flow chart of clinical article selection for the review of post discharge early follow up clinics

Appendix C. Forest plots

C.1. Post discharge early follow up clinic versus no post discharge clinic

Figure 2Mortality (heart failure patients)

Figure 3Mortality (general medical patients)

Figure 4Avoidable adverse events (urgent transplantation)

Figure 5ED attendance

Figure 6Quality of life

Figure 7Quality of life

Figure 8Readmission (heart failure patients readmitted for any cause)

Figure 9Readmission (general medical patients)

Figure 10Readmission due to heart failure (heart failure patients)

Appendix D. Clinical evidence tables

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Appendix E. Economic evidence tables

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Appendix F. GRADE tables

Table 6Clinical evidence profile: post discharge clinics versus no post discharge clinics

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Attendance at a post discharge early follow up clinic versus no post discharge early follow up clinic	Control	Relative (95% CI)	Absolute	Quality	Importance
Mortality (follow-up 3-12 months; assessed with: number of deaths)
8	randomised trials	serious¹	no serious inconsistency	serious²	no serious imprecision	none	65/649 (10%)	18%	RR 0.53 (0.4 to 0.7)	85 fewer per 1000 (from 54 fewer to 108 fewer)	⨁⨁◯◯ LOW	CRITICAL
Mortality (follow-up 12 months; assessed with: number of deaths)
1	randomised trials	no serious risk of bias	no serious inconsistency	serious²	no serious imprecision	none	244/947 (25.8%)	26.5%	RR 0.97 (0.84 to 1.13)	8 fewer per 1000 (from 42 fewer to 34 more)	⨁⨁⨁◯ MODERATE	CRITICAL
Avoidable adverse events (follow-up 12 months; assessed with: urgent transplantations)
1	randomised trials	serious¹	no serious inconsistency	serious²	serious³	none	1/112 (0.89%)	0%	OR 8.08 (0.16 to 408.63)	-	⨁◯◯◯ VERY LOW	CRITICAL
ED attendance (follow-up 12 months; assessed with: number of ED visits)
1	randomised trials	serious¹	no serious inconsistency	serious²	no serious imprecision	none	657/915 (71.8%)	70.6%	RR 1.02 (0.96 to 1.08)	14 more per 1000 (from 28 fewer to 56 more)	⨁⨁◯◯ LOW	CRITICAL
Quality of life (follow-up 3 months; measured with: Minnesota Living With Heart Failure Questionnaire; Better indicated by lower values)
1	randomised trials	very serious¹	no serious inconsistency	serious²	serious³	none	51	47	-	MD 11 lower (19.39 to 2.61 lower)	⨁◯◯◯ VERY LOW	CRITICAL
Quality of life (follow-up 12 months; measured with: time trade-off; Better indicated by lower values)
1	randomised trials	serious¹	no serious inconsistency	serious²	serious³	none	112	122	-	MD 0.09 higher (0.04 to 0.14 higher)	⨁◯◯◯ VERY LOW	CRITICAL
Readmission (assessed with: number of heart failure patients readmitted for any cause)
2	randomised trials	serious¹	no serious inconsistency	serious²	no serious imprecision	none	22/170 (12.9%)	37%	RR 0.38 (0.2 to 0.73)	229 fewer per 1000 (from 100 fewer to 296 fewer)	⨁⨁◯◯ LOW	CRITICAL
Readmission (follow-up 12 months; assessed with: number of general medical patients readmitted)
1	randomised trials	no serious risk of bias	no serious inconsistency	serious²	no serious imprecision	none	535/903 (59.2%)	58.4%	RR 1.01 (0.94 to 1.1)	6 more per 1000 (from 35 fewer to 58 more)	⨁⨁⨁◯ MODERATE	CRITICAL
Readmission due to heart failure (follow-up 3-12 months; assessed with: number of patients readmitted due to heart failure)
5	randomised trials	serious¹	serious⁴	serious²	serious³	none	88/427 (20.6%)	25.5%	RR 0.7 (0.47 to 1.05)	76 fewer per 1000 (from 135 fewer to 13 more)	⨁◯◯◯ VERY LOW	CRITICAL

1: Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias.
2: Downgraded by 1 or 2 increments because the majority of the evidence was based on indirect comparisons.
3: Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.
4: Downgraded by 1 or 2 increments because Heterogeneity, I2=50%, p=0.04, unexplained by subgroup analysis.

Appendix G. Excluded clinical studies

Table 7Studies excluded from the clinical review

Study	Exclusion reason
Angaran 2015¹	Not review population (patients were discharged from the ED, patients requiring hospitalisation were excluded); Inappropriate comparison (no comparator)
Batterham 2014²	Incorrect interventions. supervised aerobic exercise rehabilitation
Broomhead 2002³	Narrative review
Cline 1998⁵	Inappropriate comparison (usual care involved follow up at an outpatient clinic in a cardiology department)
Cuthbertson 2007⁶	Study protocol (no data)
Gonseth 2004¹¹	Systematic review is not relevant to review question or unclear PICO
Gorthi 2014¹²	Systematic review is not relevant to review question or unclear PICO
Harrison 2002¹³	Incorrect interventions (no post discharge clinic)
Jaarsma 1999¹⁴	Incorrect interventions (no post discharge clinic)
Mehlhorn 2014¹⁸	Systematic review is not relevant to review question or unclear PICO
Paratz 2014²¹	Study protocol (no data)
Powell 2010²²	Incorrect interventions (1 year patient education program)
Rainville 1999²³	Incorrect interventions (no post discharge clinic)
Schandl 2012²⁴	Inappropriate study design (cohort study)

Appendix H. Excluded health economic studies

No relevant studies identified.

Bookshelf ID: NBK564915

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