The effect of a telephone follow-up call for older patients, discharged home from the emergency department on health-related outcomes: a systematic review of controlled studies

This systematic review was done following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [23, 24].

Only two controlled studies, both RCTs, met the inclusion criteria for this review. Both studies reported no effect of a TFU call from a nurse for older patients, discharged home from the ED on hospital admission or ED return visit rates within 30 or 35 days after the index ED visit. However, only the Biese et al. 2018 study was powered to find a significant difference on this outcome [27]. The Biese et al. 2014 study reported that patients in the TFU group had significantly more often a physician appointment scheduled within 5 days than patients in the placebo and the control group. This effect was not found in the other included study, examining differences in scheduled physician appointments within 30 days. TFU was not shown to be helpful in obtaining prescribed medications or knowledge of name, dosage, and indication of prescribed medications.

Although patients who were included in the studies were well accessible by telephone for follow-up calls, many eligible patients were not reached and hence could not be approached for participation. Moreover, a substantial number of eligible patients refused to participate. This questions the feasibility of the intervention in daily practice.

The findings of the studies included in this systematic review are in accordance with other systematic reviews that examined the effects of TFU after hospital admission in (adult) patients of all ages. Crocker et al. evaluated the impact of TFU, performed by primary care personnel, after hospital admission on ED visit and hospital readmission rates in adults of all ages and did not found TFU to be beneficial [20]. Authors of a 2006 Cochrane review and a review of Bahr et al. found inconclusive evidence about the effects of TFU after hospital discharge. In the included studies, TFU was performed in a large variety of ways and by different kinds of health care professionals in different patient populations. Most studies were of low methodological quality, and many different outcomes were measured, ranging from outcomes related to health services utilization to physical and psychosocial health outcomes. Effects were not constant across the included studies and overall, and the evidence was inconclusive [13, 21]. In 2019 Nasser et al. published a review evaluating the effect of TFU on compliance with follow-up and discharge instructions in older patients, discharged home from the ED. It was concluded that TFU can identify non-compliance with discharge instructions, but evidence to improve compliance was not found [22].

Some previously published uncontrolled studies reported that TFU after ED discharge was feasible as only few patients declined participation or were not reached [17, 28]. The patients in the included studies in our review were also well accessible by phone for follow-up. However, this may reflect participation bias, as in one of the studies many eligible patients were not reached by phone and therefore could not be approached for inclusion. These may well have been patients with physical or other impairments who were unable to answer the telephone, but could have benefited from TFU [17]. Problems concerning telephone accessibility of patients are also mentioned in other studies [14, 21, 29]. Many studies report the lack of a correct phone number, which could be addressed by verifying the patient’s telephone number at discharge. The telephone number of a caregiver or family member can also be asked in case the patient cannot be reached for TFU. It is probable that for many older patients, involvement of family members or other caregivers in TFU increases accessibility and improves discharge plan adherence and other postdischarge outcomes [29, 30]. A substantial number of eligible patients refused to participate. This was also reported in a study, investigating the effect of telephone support calls by volunteers on feelings of loneliness and depression by older patients, discharged home from the ED. [31] Patients may have refused participation, because they did not want to be involved in a study, but they may also judge TFU as unnecessary interference. Although less time-consuming than other transitional care programs, TFU still requires sufficient staff to approach all eligible patients [21]. This is illustrated in the Biese et al. 2014 study, enrolling patients only on specific weekdays and up to a maximum of nine per day, because they did not have enough staff to perform more telephone calls [26]. Not including patients on other weekdays may undoubtedly have led to missing eligible patients who presented outside this inclusion window. The substantial number of eligible patients that was not reached or refused participation underlines the efforts that are needed to make FTU feasible in daily practice [26, 27, 31].

The studies included in this review investigated the effect of TFU on health services utilization and understanding of and compliance with discharge instructions. The effects of TFU on other, more difficult to measure outcomes, such as psychosocial health outcomes, were not measured. A systematic review investigating older patients’ expectations of emergency care reported that insufficient or poorly understood explanations about diagnosis or discharge instructions were associated with less satisfaction with care [32]. It may be that with TFU ED staff could meet these expectations by providing additional explanations and care. Besides that, TFU can be regarded as a socially complex intervention, characterized by difficult to define and to standardize interactions and by various contextual factors, which may mask potential effects. To support this idea, the Dutch Patients and Costumers Federation stated that TFU deserved a place in aftercare, despite the negative findings of the 2006 Cochrane review, because patients had indicated that they highly appreciated the call [13]. In accordance with this, some studies suggest that several older patients are in need of social and emotional support following an ED visit and that (repetitive) TFU could provide for this [28, 31]. It would be worth exploring in future research how care transition interventions after an ED visit affect perceived emotional and social support and specific needs and barriers that older ED users experience [30].

The limited number of controlled studies concerning this subject is remarkable, given the increasing number of proactive care programs for older patients in many EDs [27]. Apart from the two studies that met the inclusion criteria for this review, we found one more suitable study. This cohort study with pre-post design, published in Dutch in a non-peer reviewed journal, also reported no effect of TFU on hospital admission or ED return visit rate within 30 days after discharge from a general hospital ED. [33] The small number of available studies, all showing no benefit of the intervention may underline the absence of effect of TFU on health-related outcomes. More controlled intervention studies are needed to investigate the effect of TFU in older ED patients. Future studies should best focus the intervention on individuals at highest risk of hospital use, such as those with functional or cognitive impairments, with mental health conditions, limited social support, or with complex medical regimens, to determine whether there are different effects of TFU in these populations [1, 30, 34]. Interesting outcome measures, in addition to health service utilization, would be functional decline, perceived social, and emotional support and feelings of anxiety or depression. Failure to reach eligible patients could be addressed by appointing sufficient staff members to perform the intervention, by verifying the patient’s telephone number at discharge and by involving the patients’ caregivers. It would also be interesting to investigate the effects and feasibility of TFU performed by other personnel than ED staff, e.g., primary care personnel or nurses from a commercial call center.

Telephone follow-up is considered to be a low-cost intervention, that probably allows the opportunity to detect problems and complications, clarify discharge instructions, and initiate other forms of aftercare for older adults discharged home from the ED. However, our systematic review of two published randomized controlled studies found no demonstrable effect of TFU for older adults, discharged from the ED on health service utilization and understanding of and compliance with discharge instructions. Furthermore, feasibility of the intervention appeared to be low. Considering the limited number of high-quality studies on this topic, more research is needed to explore whether TFU is an effective and feasible intervention to reduce hospitalization and ED return visit rates or to improve older patients’ discharge plan adherence after an ED visit. In future studies, it is important to also investigate whether TFU promotes psychosocial wellbeing in older patients after ED discharge.