Response to Letter Regarding Article, "Temporal Trends and Variation in Early Scheduled Follow-up After a Hospitalization for Heart Failure: Findings from Get With The Guidelines-Heart Failure.

We thank Dr Ezekowitz and McAlister for their interest in our work on early outpatient follow-up after a hospitalization for heart failure. The investigators raise an interesting question: what proportion of early follow-up appointments was planned to be with a familiar provider? A prior analysis from their group identified an association between provider continuity and improved outcomes after a hospitalization for heart failure in Canada. However, whether these findings extend to other settings, including the United States, are unknown. For example, in a prior analysis of Medicare beneficiaries hospitalized with heart failure, early follow-up with a physician from the index hospitalization was not associated with 30-day readmission rates. The question posed by these authors raises a larger issue. What are the unintended consequences, or “off-target effects,” of early follow-up? Certainly, there are financial implications for increased clinic appointments after a heart failure hospitalization, though these are presumably offset by reduced hospitalizations. Could early follow-up also strain healthcare systems and lead to decreased access to care for some or increased fragmentation of care for heart failure patients? Evaluating these questions through observational research alone is challenging given the other changes simultaneously occurring in United States healthcare. For example, there is growing interest in alternative healthcare delivery models for patients with heart failure, including acute care clinics, that may also lead to fragmentation of care, and providers rarely operate as solo providers in heart failure care today. Instead, follow-up care can be performed through a multidisciplinary disease management team that may not be captured through physician billing codes. To evaluate this and other issues in chronic disease management, we strongly advocate for an improved evidence base through randomized trials of transitional care interventions. There are now multiple platforms in the United States which can embed large, pragmatic, clinical trials within healthcare delivery systems, including the National Institutes of Health Collaboratory and the National Patient-Centered Clinical Research Network (PCORnet), to fully evaluate transitional care interventions before widespread implementation.