What's new in emergencies trauma and shock? Outpatient follow-up after traumatic injury: Challenges and opportunities.

The authors present data on the follow-up of trauma patients after discharge from acute care. They evaluated 2,906 trauma patients of whom approximately a third presented to the index institution for scheduled follow-up within the 2 months period immediately following discharge. The authors report that uninsured patients, as well as persons with Medicaid coverage, were less likely to present for scheduled follow-up outpatient visits and were more likely seen in the emergency department (ED) for any cause within 2 months after discharge than patients with private insurance or Medicare coverage.

We applaud the authors for examining this very important topic and recognize the challenges associated with a study of this nature. We are concerned that the unavailability of data on patients lost to follow-up weaken the generalizability of the findings from this study, which may be subject to “attrition bias”.[1] Understanding what may have happened to, in this case the majority of patients, forms an important piece of the puzzle in any analysis of this kind.[2] We are also concerned that using all-cause ED admission as a marker of recidivism may introduce bias — it is possible that those patients who are uninsured or on Medicaid may have other comorbid illnesses or may be at greater risk of injury, and therefore, might be significantly more likely to present for emergency treatment for conditions not related to the primary cause of index treatment compared with those individuals carrying private or Medicare coverage.

Insurance coverage and type are known to be associated with patient age.[234] Other studies have reported age- and gender-related patterns in both recidivism and in the likelihood of presenting for scheduled post-discharge follow-up care among trauma patients.[56] In addition, the absence of detailed information on individual patient comorbidities may bias the study findings. We appreciate that the authors do mention this issue as a limitation of their study; however, we believe that these factors warrant deeper investigation and should be more fully accounted for in future studies. Also, the presence of coexisting illnesses in persons suffering acute trauma may be an indication for more intensive follow-up after discharge and put such patients at increased risk of unscheduled ED presentation.[78]

Attributing the likelihood of participating in scheduled follow-up to the type or lack of health insurance coverage appears to have validity on its face; however, the lack of information on those patients who do not present for scheduled follow-up, along with an inadequate ability to understand and control for other coexisting illnesses, limits the potential impact of this otherwise well done study. As the US healthcare system moves toward the “accountable care” model, developing a more complete understanding of the patterns of how patients as individuals and in groups use, or fail to take advantage of, healthcare resources and provider recommendations will be critically important. We commend the authors for their vision and for their effort in studying this very challenging and complex topic in trauma patients and we look forward to further and increasingly robust study from their group.