Family Practice Vol. 21, No. 3, 314-316
Family Practice Vol. 21, No. 3 © Oxford University Press 2004, all rights reserved.
Duration of symptoms and follow-up patterns of patients discharged from the emergency department after presenting with abdominal or flank pain
Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, a University of Michigan School of Medicine, Ann Arbor, MI and b Princeton University, Princeton NJ, USA
Correspondence to J Tobias Nagurney, MD MPH, Department of Emergency Medicine, Clinics 115, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02115, USA; E-mail: nagurney.john{at}mgh.harvard.edu
Received 7 May 2003; Revised 10 November 2003; Accepted 7 January 2004.
Weiner JB, Nagurney JT, Brown DFM, Sane S and Wang AC. Duration of symptoms and follow-up patterns of patients discharged from the emergency department after presenting with abdominal or flank pain. Family Practice 2004; 21: 314–316.
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Abstract |
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Background. Little is known about the duration of symptoms and follow-up patterns of patients seen in emergency departments for abdominal or flank pain.
Objective. We aimed to measure the duration of symptoms and follow-up rate of patients discharged home from the emergency department after presenting with non-traumatic abdominal or flank pain.
Methods. We conducted a single-centre, prospective descriptive study of adult patients who presented to our emergency department with non-traumatic abdominal or flank pain and were discharged from the emergency department. We gathered clinical data during the index emergency department visit and conducted telephone interviews of subjects 2–5 weeks later.
Results. We reached 63 of 90 subjects (70%). The median duration of pain was 3 days after the emergency department visit. During the follow-up period, only 41% had followed-up with their family physician or primary care provider, although an additional 21% had planned to. Persistence of symptoms was common in the 37% of subjects who did not follow-up.
Conclusion. Of subjects discharged from the emergency department after visits for non-traumatic abdominal or flank pain, most improve within several days. Fewer than half follow-up with a family practitioner or a primary care provider. Emergency department revisits are uncommon and often for unrelated problems.
Keywords. Abdominal pain, follow-up, natural history, telephone.
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Introduction |
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Abdominal or flank pain represents an important problem for family and primary care practice. Furthermore, it is often difficult to diagnose and in many instances the diagnosis may be incorrect.1,2 Very few studies link emergency visits and data on follow-up visits to family practitioners or primary care providers.3–5 Telephone interviews are one possible way to do this, having been used successfully to follow-up emergency department patients, with contact rates of 48–94%.6,7
We undertook this study to learn more about the duration of symptoms and the follow-up patterns of adult patients who were discharged home from the emergency department.
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Methods |
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Study population
We conducted a prospective descriptive pilot study using the emergency department of an urban 73 000 annual visit university hospital. All adult patients presenting to this department with a complaint of pain in the abdomen or flank and not related to trauma were eligible. The intake period was July 10 to August 15, 2001, weekdays from 9 a.m. to 5 p.m. All patients were screened for eligibility and were excluded if they had unstable vital signs or could not provide informed consent.
The routine practice is that most patients self-refer to the emergency department because of what they perceive to be acute medical problems, with only a small minority referred by a family practitioner. After completion of their emergency department evaluation, emergency department physicians routinely review the most likely final emergency department diagnosis and follow-up plans with patients. Patients are also given both written and verbal discharge instructions by their primary nurse. All patients are encouraged to contact their family practitioner or primary care provider within a few days of the emergency department visit, and to be re-examined if they do not improve quickly. Patients who do not have a primary care provider or family practitioner are referred to one.
Investigators performed baseline screening and obtained informed consent and most recent telephone numbers, and interviewed each subject's emergency department primary provider by means of a closed-ended questionnaire.
Subjects discharged home from the emergency department were interviewed by a follow-up structured telephone interview within 2–5 weeks. A maximum of five calls was attempted before the subject was considered unreachable. Subjects were asked about duration of their pain, if they had followed-up with a family practitioner after their emergency department visit, and details of any office-based tests or diagnoses. Subjects were also asked about any return visits to an emergency department. For subjects not reached by telephone, medical records were reviewed to see if they had any return visits to the emergency department during this 5-week follow-up period.
Data analysis
All data was keypunched into an Excel database. Simple descriptive statistics including means, medians, standard deviations, interquartile ranges and 95% confidence intervals (CIs) were used. This study was approved by our institutional review board.
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Results |
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The overall enrolment in this follow-up study was 90 subjects. The mean age was 43 years (SD 16) and 43% were male; 80% of subjects had abdominal pain, 17% had flank pain and 3% had both. We attempted to call all 90 subjects and reached 63 (70%; 95% CI 59–79). The most common final diagnoses based on the emergency department evaluation are listed in Table 1.
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Follow-up: pain duration
Among those 63 subjects reached by phone, 42 (67%; 95% CI 55–79) reported that their pain had improved or resolved since the emergency department visit. The median time from this visit to resolution of pain was 3 days (range 0.08–14 days, interquartile range 2–4).
Follow-up: overall compliance
Among the 63 subjects reached by telephone, at the time of the follow-up call, 26 subjects (41%; 95% CI 29–53) had already followed-up with their family practitioner. An additional 13 subjects (21%; 95% CI 11–31) had planned to, but the remaining 24 (36%; 95% CI 24–48) had not. Of these 37 who had not yet followed-up or did not plan to, 11 subjects (30%; 95% CI 15–45) still had ongoing pain.
Follow-up: family practitioner office and emergency department visits
Of the 26 patients who had followed-up with their family practitioner, 20 (77%; 95% CI 61–93) had office visits only, one subject (4%) had only a follow-up phone call, and five (19%) had emergency department visits in addition to their office follow-up visit.
Thirteen subjects (14%; 95% CI 7–21) revisited the emergency department within 5 weeks of the original emergency department visit, seven for related problems. Of the seven, five were admitted.
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Discussion |
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Natural history of abdominal pain
In our study, among those two-thirds of subjects that we successfully contacted by telephone, the median duration of pain after the emergency department visit was 3 days. In a retrospective study examining 307 adult patients who were discharged from an urban emergency department with the diagnosis of undifferentiated abdominal pain, Lukens found that 57% were improved or pain free within 2–3 days of the emergency department index visit, and 88% within 2–3 weeks.3 Shesser found that 82% of patients reported improvement in their condition within 3 days of emergency department discharge.4 This study differed from ours, however, in that only 21% of subjects had presented with acute abdominal pain.
Follow-up with family practitioner or return to the emergency department
In our study, among those subjects reached by telephone, 41% had followed-up with their family practitioner within the follow-up period. It is of note that among those 36% of subjects who had not yet followed-up nor planned to, 30% still had ongoing pain. Eight percent of subjects revisited the emergency department for a related problem; with an admission rate of 6%.
In Lukens' study, only 25% of patients had seen a physician by the 2–3 week follow-up phone call, and only 10 patients (3%) were admitted to the hospital over this follow-up period for problems related to abdominal pain.3 However, this study design was retrospective and their follow up-period was briefer than ours.
In a Dutch study of adult patients seen in the emergency department for abdominal symptoms and based on a follow-up written questionnaire, 46% of the 663 patients who responded (81% of the study population) had visited their GP, and 48 (7%) had revisited an emergency department.5 Of these 48 patients, 17 (3%) were admitted. Despite representing medical practice in a country dissimilar to the USA, the rates for follow-up for out-patient visits and returns to the emergency department were similar to our findings. This relatively low and reproducible follow-up rate represents a concern. Further research should focus on the reasons for it and ways to improve it.
Conclusion
Over two-thirds of emergency department patients seen for abdominal or flank pain and discharged can be reached by telephone for a follow-up interview; pain improvement occurs in the majority of subjects within 3 days. Just under half of those who can be reached have followed-up with a family physician within 2–5 weeks, despite ongoing symptoms in a sizeable minority who have not. Emergency department revisits are uncommon and often for unrelated problems.
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Acknowledgments |
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We thank the house, nursing and attending staff of our institution for co-operating with our provider interviews and data gathering, and Shannon Lunnin for manuscript preparation advice. JTN conceived the study, supervised the data gathering and management, and rewrote the final draft. DFB assisted supervising the data gathering and commented on the final draft. JW wrote the first version of the paper and assisted in data gathering. SS assisted in data gathering and managed and cleaned the database. AC assisted in data gathering. JTN takes responsibility for the paper as a whole.
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References |
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1 Graff L, Russell J, Seashore J et al. False-negative and false-positive errors in abdominal pain evaluation: failure to diagnose acute appendicitis and unnecessary surgery. Acad Emerg Med 2000; 7: 1244–1255.[Medline]
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5 van Geloven AA, deVries GM, van der Eerden MM, Luitse JS, Hoitsma HF, Obertop H. Prospective follow-up of patients with abdominal symptoms treated by emergency room physicians. Ned Tijdsschr Geneeskd 1999; 143: 529–530.
6 Horne AR. Telephone follow-up of patients discharged from the emergency department: how reliable? Pediatr Emerg Care 1995; 11: 173–175.[Web of Science][Medline]
7 Issacman DJ, Khine H, Losek JD. A simple intervention for improving telephone contact of patients discharged from the emergency department. Pediatr Emerg Care 1997; 13: 256–258.[Web of Science][Medline]
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