A 4-year-old child is being discharged after a 3-day hospitalization for pneumonia that included treatment with supplemental oxygen and antibiotic therapy. The hospitalist instructs the child’s mother to schedule a follow-up appointment with the child’s primary care provider (PCP) within the coming week. The mother makes an appointment and calls her manager at work to ask if she can miss part of work that day for the appointment. Her manager mentions that she has already missed several days of work recently (related to the child’s medical care) but ultimately grants her the additional time away. Within 2 days of hospital discharge, the mother notes that the child seems to have recovered from her illness and is back to her normal self. Nevertheless, she takes the child to her follow-up appointment because that was the recommendation provided by the hospitalist. The child’s PCP concurs with the mother’s assessment that the child appears to have completely recovered from the illness. The mother appreciates the reassurance from the child’s PCP but also wonders if the visit, the co-pay, and the time away from work were really necessary.
Automatic Follow-up Has Intuitive Appeal
Most hospitalized children are prescribed automatic posthospitalization follow-up, that is, they are routinely instructed to visit their PCP shortly after hospital discharge, regardless of symptom improvement. For example, one multicenter study of 198 children hospitalized for bronchiolitis revealed that 84% of parents were given instructions for automatic follow-up.1 The high rate of automatic follow-up recommendations is perhaps unsurprising given that automatic follow-up is considered the standard of care2 and has been proposed (and implemented by at least 1 hospital3 ) as a quality metric.4
The intuitive appeal of automatic follow-up is to smooth the transition from hospital to home. Follow-up visits provide an opportunity for PCPs to connect with patients and their families to verify that a patient is following an expected course, adjust the treatment regimen if needed, provide additional education and reassurance about the patient’s illness, and address any gaps in continuity of care. Although not consistently shown to improve outcomes, the practice of recommending automatic follow-up is particularly appealing for children who have chronic and/or complex medical needs because they are at increased risk for adverse events5,6 and readmission.7–10 For this reason, discharge improvement interventions that include automatic follow-up have been focused on populations of children with chronic and/or complex medical needs, such as children hospitalized for asthma,11 premature birth,12,13 or major surgery.14 The necessity of automatic follow-up has been extrapolated to all hospitalized children, although the benefit/harm ratio is likely different for previously healthy children.
Is Automatic Follow-up Always Necessary?
In contrast to hospitalized adults, the majority of hospitalized children are previously healthy and admitted for acute conditions from which complete recovery is expected.15,16 In fact, 5 of the top 10 reasons for pediatric hospitalization are infections: pneumonia, bronchiolitis, skin and soft tissue infections, gastrointestinal infections, and urinary tract infections.16 Once discharged from the hospital, the vast majority of previously healthy children quickly recover from these acute conditions and rarely experience an interim worsening of their disease (readmission rates are <5%9 ). Given such a reassuring prognosis, it is unclear whether previously healthy children recovering from acute conditions benefit from automatic follow-up.
Observational studies examining automatic posthospitalization follow-up have reached conflicting conclusions, with some studies finding an association between automatic follow-up and decreased rates of hospital readmission17–23 and other studies finding no association or even increased rates of hospital readmission.3,24–28 Observational studies of posthospitalization follow-up are particularly susceptible to bias because illness severity likely confounds the relationship between follow-up visit attendance and patient outcomes. The only randomized controlled trial to date is the Bronchiolitis Follow-up Intervention Trial (BeneFIT), a noninferiority trial that randomly assigned previously healthy children hospitalized for bronchiolitis to automatic posthospitalization follow-up versus as-needed (PRN) follow-up. BeneFIT revealed that fourfold fewer families (19% vs 81%) chose to attend posthospitalization follow-up visits when randomly assigned to PRN versus automatic follow-up, but the 2 groups otherwise experienced similar outcomes, including parent anxiety, symptom duration, hospital readmission, and satisfaction with care.29
An Alternative Strategy: PRN Follow-up
There are undoubtedly clinical scenarios for which automatic follow-up will be appropriate. For example, perhaps a child does not have a PCP or has not seen their PCP for an extended period of time, in which case an automatic follow-up visit can serve as an opportunity to connect. Or perhaps a child has had a particularly tumultuous hospitalization, and their parents are not comfortable with the responsibility of verifying disease resolution. Indeed, in the BeneFIT trial, a portion of eligible participants were excluded because of the hospitalist (8%) or parents (10%) not being comfortable with the possibility of being randomly assigned to PRN follow-up. However, in the absence of a compelling reason for automatic follow-up, PRN follow-up is a reasonable default option. PRN follow-up is a patient- and family-centered follow-up strategy that encourages families to monitor their child’s symptoms after hospital discharge and schedule a visit if the child does not improve or if new concerns arise. As such, PRN follow-up empowers families with greater autonomy. Taking this decision-making away from families runs the risk of undermining their sense of self-efficacy, a patient’s or parent’s confidence to solve self-identified problems.30
Advantages of PRN Follow-up
In addition to patient and family centeredness, PRN follow-up offers several potential advantages. The first advantage is time and cost savings for families. Clinic visits require an average of 2 hours of a patient’s time and result in out-of-pocket expenses and lost income.31 Out-of-pocket expenses include money for co-pays, travel, parking, and child care. These burdens disproportionately affect historically underserved patient populations. For example, attendance of a clinic visit requires 30% more time for Hispanic and non-Hispanic Black families compared with non-Hispanic white families.32 Lost income occurs when parents take time away from work to attend the visit, which is particularly challenging for parents who may have taken time away from work during their child’s hospitalization or are more precariously employed. Lost income during this time is highest for single-parent households and those reporting greater social or financial hardships.33 PRN follow-up could mitigate these burdens.
A second advantage of PRN follow-up is decreased risk of overtreatment. Seemingly benign medical interventions can precipitate additional tests and interventions that are unnecessary, costly, and potentially harmful. The Hospital to Home Outcomes Trial randomly assigned hospitalized children to a nurse-led home visit versus no home visit after discharge, revealing that nurse-led home visits increased revisits to the hospital.34 The Hospital to Home Outcomes II Trial randomly assigned hospitalized children to a nurse-led phone follow-up versus no phone follow-up after discharge and measured greater hospital revisits among children randomly assigned to phone follow-up (although the increase was not statistically significant).35 Paradoxically, efforts to augment posthospitalization follow-up increased rates of hospital revisit. Similarly, BeneFIT revealed that children who attended follow-up visits received new prescriptions for antibiotics, albuterol, and inhaled corticosteroids.29 The American Academy of Pediatrics bronchiolitis guideline states that these medications should not be routinely used to treat bronchiolitis.36 Taken together, findings from these trials suggest that efforts to increase follow-up can lead to further medical care of unclear benefit. By allowing a family whose child is recovering as expected to avoid a posthospitalization follow-up visit, PRN follow-up might reduce the child’s exposure to overtreatment.
A third advantage of PRN follow-up is decreased risk of health care–associated infections. Health care facilities are a well-described source of spread of contagious diseases. For example, family members of children who attend well-child check-up visits are more likely to have an influenzalike illness within the 2-week period after the visit compared with families of children who did not attend such a visit.37 By avoiding unnecessary clinic visits, PRN follow-up can reduce infectious exposures between children, their families, and their health care providers.
Additional Considerations and Conclusions
Telehealth is an emerging option for posthospitalization follow-up that could provide some of the same benefits as PRN follow-up while still providing an opportunity for a check-in between a family and their child’s PCP. However, telehealth is presently less available for families who have lower incomes, live rurally, or have limited English proficiency.38,39 Furthermore, telehealth visits can still lead to overtreatment40,41 and overmedicalization.42 Greater investigation is needed before telehealth can be actively promoted as an option for posthospitalization follow-up.
Although posthospitalization follow-up is probably warranted in certain cases, there may be unintended harms to automatically instructing all hospitalized children to attend a posthospitalization follow-up visit. For previously healthy children recovering from acute conditions, PRN follow-up represents a patient- and family-centered alternative to automatic follow-up. By the time hospital discharge arrives, a parent has seen their child at their sickest and seen them get better. Perhaps we should trust them more often to continue monitoring their child’s recovery after discharge and decide if a follow-up appointment will be valuable for their child and their family. If the parent in the vignette had been given a PRN follow-up recommendation for her child, she could have avoided the time, hassle, and expense of attending an unnecessary visit.
FUNDING: No external funding.
Dr Coon drafted the initial manuscript; Drs Conroy and Ray reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.
References
Competing Interests
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
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