Predictors of patient adherence to follow-up recommendations after an ED visit



      It is unclear whether factors identified during the emergency department (ED) visit predict noncompliance with ED recommendations.

      Study objective

      We sought to determine predictors of adherence to medical recommendations after an ED visit.


      We conducted a prospective, observational study at a single urban medical center. Eligible ED patients provided baseline demographic data as well as information regarding insurance status, whether they had a primary care physician (PCP), and the impact of cost of care on their ability to follow medical recommendations. Patients were contacted at least 1 week after the ED visit and answered questions regarding adherence to medical recommendations.


      Four hundred twenty-two patients agreed to participate in the study. At follow-up, 89.7% of patients reported that they had complied with recommendations made during the ED visit. Patients who were adherent to follow-up recommendations were more likely to have a primary care provider (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.1-6.1), have an annual income of greater than $35000 (OR, 2.9; 95% CI, 1.2-7.2), and report a non-Hispanic ethnicity or race (OR, 2.8; 95% CI, 1.1-7.1). Individuals who reported that cost “sometimes” or “always” impacts their ability to follow their physician's recommendations were significantly less likely to comply with ED recommendations (OR, 2.7; 95% CI, 1.3-5.6).


      Individuals who reported that cost affects their ability to follow their physician's recommendations and those who did not have a PCP were less likely to follow ED recommendations. Identification of predictors of noncompliance during the ED visit may aid in ensuring compliance with ED recommendations.
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        • Lowsky D.
        • Ramya C.
        • Hussey P.S.
        • Mulcahy A.
        • Vaiana M.E.
        • Kellermann A.L.
        Flattening the trajectory of health care spending: engage and empower consumers.
        RAND Corporation, Santa Monica, CA2012 ([ Accessed January 25, 2014])
        • Auerbach D.
        • Kellermann A.L.
        How does growth in health care cost affect the American family?.
        RAND Corporation, Santa Monica, CA2011 ([ Accessed November 30, 2013])
        • Collins S.R.
        • Robertson R.
        • Garber T.
        • Doty M.M.
        Insuring the future: current trends in health coverage and the effects of implementing the Affordable Care Act.
        The Commonwealth Fund. 2013 ([ Accessed January 8, 2014.])
        • Zafar S.Y.
        • Peppercorn J.M.
        • Schrage D.
        • Taylor D.H.
        • Goetzinger A.M.
        • Zhong X.
        • et al.
        The financial toxicity of cancer treatment: a pilot study assessing out-of-pocket expenses and the insured cancer patient's experience.
        Oncologist. 2013; 18: 381-390
        • Sommers A.
        • Cunningham P.J.
        Medical bill problems steady for U.S. families, 2007-2010.
        in: Tracking report/Center for Studying Health System Change. 28. 2011: 1-5 ([Accessed January 15, 2014])
        • Cohen R.
        • Gindi R.
        • Kirzinger W.
        Burden of medical care cost: early release of estimates from the National Health Interview Survey, January-June 2011.
        National Center for Health Statistics, 2012 ([ Published March 2012. Accessed January 20, 2014])
        • Martin L.R.
        • Williams S.L.
        • Haskard K.B.
        • Dimatteo M.R.
        The challenge of patient adherence.
        Ther Clin Risk Manag. Sep 2005; 1: 189-199
        • Morris L.S.
        • Schulz R.
        Patient compliance—an overview.
        J Clin Pharm Ther. 1992; 17: 283-295
        • National Center for Health Statistics
        Health, United States, 2012 with special features on emergency care.
        in: Health and Human Services-(HHS). DHHS, Hayettsville, MD2012 ([ Accessed September 12, 2013])
        • Bureau of Emergency Medical Services
        • Preparedness and Office of Health Care Statistics
        Utah emergency department utilization and charges profile statewide summary (Utah emergency department annual report EDAR-2010).
        2010 ([Salt Lake City, Utah 2010. Published June 30, 2011. Accessed Septemer 20, 2013])
        • Ding R.
        • McCarthy M.L.
        • Li G.
        • Kirsch T.D.
        • Jung J.J.
        • Kelen G.D.
        Patients who leave without being seen: their characteristics and history of emergency department use.
        Ann Emerg Med. Dec 2006; 48: 686-693
        • De Araujo P.
        • Khraiche M.
        • Tukan A.
        Does overcrowding and health insurance type impact patient outcomes in emergency departments?.
        Heal Econ Rev. 2013; 3: 25
        • University of Utah Healthcare
        University of Utah Health Care.
        2012 ([ Accessed December 15, 2013])
        • Allan G.M.
        • Innes G.D.
        Do family physicians know the costs of medical care? Survey in British Columbia.
        Can Fam Physician. Feb 2004; 50: 263-270
        • Innes G.
        • Grafstein E.
        • McGrogan J.
        Do emergency physicians know the costs of medical care?.
        CJEM. 2000; 2: 95-102
        • Sehgal R.T.
        • Gorman P.
        Internal medicine physicians' knowledge of health care charges.
        J Grad Med Educ. 2011; 3: 182-187
        • Groves R.M.
        • Fowler Jr., F.J.
        • Couper M.P.
        • Lepkowski J.M.
        • Singer E.
        • Tourangeau R.
        Survey methodology.
        John Wiley & Sons, Hoboken, NJ2009
        • Agency for Heathcare Research and Quality
        Health literacy measurement tools: fact sheet.
        2009 ([ Accessed August 2, 2012])
        • Morisky D.E.
        • DiMatteo M.R.
        Improving the measurement of self-reported medication non-adherence: response to authors.
        J Clin Epidemiol. 2011; 64 ([discussion 258–263]): 255-257
        • Harris P.A.
        • Taylor R.
        • Thielke R.
        • Payne J.
        • Gonzalez N.
        • Conde J.G.
        Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support.
        J Biomed Inform. 2009; 42: 377-381
        • Passmore C.
        • Dobbie A.E.
        • Parchman M.
        • Tysinger J.
        Guidelines for constructing a survey.
        Fam Med. 2002; 34: 281-286
        • Carlson M.D.
        • Morrison R.S.
        Study design, precision, and validity in observational studies.
        J Palliat Med. Jan 2009; 12: 77-82
        • Vermeire E.
        • Hearnshaw H.
        • Van Royen P.
        • Denekens J.
        Patient adherence to treatment: three decades of research. A comprehensive review.
        J Clin Pharm Ther. Oct 2001; 26: 331-342
        • Saunders C.E.
        Patient compliance in filling prescriptions after discharge from the emergency department.
        Am J Emerg Med. Jul 1987; 5: 283-286
        • Dalawari P.
        • Patel N.
        • Bzdawka W.
        • Petrone J.
        • Liou V.
        Attitudes of cost and related barriers to prescription medications.
        ACEP, Denver, CO2011
        • Baker L.C.
        • Baker L.S.
        Excess cost of emergency department visits for nonurgent care.
        Health Aff (Millwood). Winter 1994; 13: 162-171
        • Cook C.L.
        Validation of the transtheoretical model in medication compliance behavior (dissertation).
        University of Georgia, GA, Athens, GA2002
        • Asplin B.R.
        • Rhodes K.V.
        • Levy H.
        • Lurie N.
        • Crain A.L.
        • Carlin B.P.
        • et al.
        Insurance status and access to urgent ambulatory care follow-up appointments.
        JAMA. 2005; 294: 1248-1254
        • Kyriacou D.N.
        • Handel D.
        • Stein A.C.
        • Nelson R.R.
        Brief report: factors affecting outpatient follow-up compliance of emergency department patients.
        J Gen Intern Med. Oct 2005; 20: 938-942