Cardiology or primary care for heart failure in the community setting: process of care and clinical outcomes

Differences in provider approach to initiating and titrating guideline directed medical therapy in heart failure with reduced ejection fraction

BACKGROUND

Despite the strong evidence supporting guideline-directed medical therapy (GDMT) in patients with heart failure with reduced ejection fraction (HFrEF), prescription rates in clinical practice are still lacking.

METHODS

A survey containing 20 clinical vignettes of patients with HFrEF was answered by a national sample of 127 cardiologists and 68 internal/family medicine physicians. Each vignette had 4-5 options for adjusting GDMT and the option to make no medication changes. Survey respondents could only select one option. For analysis, responses were dichotomized to the answer of interest.

RESULTS

Cardiologists were more likely to make GDMT changes than general medicine physicians (91.8% vs. 82.0%; OR 1.84 [1.07-3.19]; p = 0.020). Cardiologists were more likely to initiate beta-blockers (46.3% vs. 32.0%; OR 2.38 [1.18-4.81], p = 0.016), angiotensin receptor blocker/neprilysin inhibitor (ARNI) (63.8% vs. 48.1%; OR 1.76 [1.01-3.09], p = 0.047), and hydralazine and isosorbide dinitrate (HYD/ISDN) (38.2% vs. 23.7%; OR 2.47 [1.48-4.12], p < 0.001) compared to general medicine physicians. No differences were found in initiating angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARBs), initiating mineralocorticoid receptor antagonist (MRA), sodium-glucose transporter protein 2 (SGLT2) inhibitors, digoxin, or ivabradine.

CONCLUSIONS

Our results demonstrate cardiologists were more likely to adjust GDMT than general medicine physicians. Future focus on improving GDMT prescribing should target providers other than cardiologists to improve care in patients with HFrEF.

Effect of implementing a heart failure admission care bundle on hospital readmission and mortality rates: interrupted time series study

This study aimed to evaluate the impact of developing and implementing a care bundle intervention to improve care for patients with acute heart failure admitted to a large London hospital. The intervention comprised three elements, targeted within 24 hours of admission: N-terminal pro-B-type natriuretic peptide (NT-proBNP) test, transthoracic Doppler two-dimensional echocardiography and specialist review by cardiology team. The SHIFT-Evidence approach to quality improvement was used. During implementation, July 2015-July 2017, 1169 patients received the intervention. An interrupted time series design was used to evaluate impact on patient outcomes, including 15 618 admissions for 8951 patients. Mixed-effects multiple Poisson and log-linear regression models were fitted for count and continuous outcomes, respectively. Effect sizes are slope change ratios pre-intervention and post-intervention. The intervention was associated with reductions in emergency readmissions between 7 and 90 days (0.98, 95% CI 0.97 to 1.00), although not readmissions between 0 and 7 days post-discharge. Improvements were seen in in-hospital mortality (0.96, 95% CI 0.95 to 0.98), and there was no change in trend for hospital length of stay. Care process changes were also evaluated. Compliance with NT-proBNP testing was already high in 2014/2015 (162 of 163, 99.4%) and decreased slightly, with increased numbers audited, to 2016/2017 (1082 of 1101, 98.2%). Over this period, rates of echocardiography (84.7-98.9%) and specialist input (51.6-90.4%) improved. Care quality and outcomes can be improved for patients with acute heart failure using a care bundle approach. A systematic approach to quality improvement, and robust evaluation design, can be beneficial in supporting successful improvement and learning.

Social Determinants of Health and Cardiologist Involvement in the Care of Adults Hospitalized for Heart Failure

Importance

Involvement of a cardiologist in the care of adults during a hospitalization for heart failure (HF) is associated with reduced rates of in-hospital mortality and hospital readmission. However, not all patients see a cardiologist when they are hospitalized for HF.

Objective

To determine whether social determinants of health (SDOH) are associated with cardiologist involvement in the management of adults hospitalized for HF.

Design, Setting, and Participants

This retrospective cohort study used data from the Reasons for Geographic and Racial Difference in Stroke (REGARDS) cohort. Participants included adults who experienced an adjudicated hospitalization for HF between 2009 and 2017 in all 48 contiguous states in the US. Data analysis was performed from November 2022 to January 2023.

Exposures

A total of 9 candidate SDOH, aligned with the Healthy People 2030 conceptual model, were examined: Black race, social isolation, social network and/or caregiver availability, educational attainment less than high school, annual household income less than $35 000, living in rural area, living in a zip code with high poverty, living in a Health Professional Shortage Area, and living in a state with poor public health infrastructure.

Main Outcomes and Measures

The primary outcome was cardiologist involvement, defined as involvement of a cardiologist as the primary responsible clinician or as a consultant. Bivariate associations between each SDOH and cardiologist involvement were examined using Poisson regression with robust SEs.

Results

The study included 1000 participants (median [IQR] age, 77.8 [71.5-84.0] years; 479 women [47.9%]; 414 Black individuals [41.4%]; and 492 of 876 with low income [56.2%]) hospitalized at 549 unique US hospitals. Low annual household income (<$35 000) was the only SDOH with a statistically significant association with cardiologist involvement (relative risk, 0.88; 95% CI, 0.82-0.95). In a multivariable analysis adjusting for age, race, sex, HF characteristics, comorbidities, and hospital characteristics, low income remained inversely associated with cardiologist involvement (relative risk, 0.89; 95% CI, 0.82-0.97).

Conclusions and Relevance

This cohort study found that adults with low household income were 11% less likely than adults with higher incomes to have a cardiologist involved in their care during a hospitalization for HF. These findings suggest that socioeconomic status may bias the care provided to patients hospitalized for HF.

Social Determinants of Health and Cardiologist Involvement in the Care of Adults Hospitalized for Heart Failure

Introduction

The involvement of a cardiologist in the care of adults during a hospitalization for heart failure (HF) is associated with reduced rates of in-hospital mortality and hospital readmission. However, not all patients see a cardiologist when they are hospitalized for HF. Since reasons for this are not entirely clear, we sought to determine whether social determinants of health (SDOH) are associated with cardiologist involvement in the management of adults hospitalized for HF. We hypothesized that SDOH would be inversely associated with cardiologist involvement in the care of adults hospitalized for HF.

Methods

We included adult participants from the national REasons for Geographic And Racial Difference in Stroke (REGARDS) cohort, who experienced an adjudicated hospitalization for HF between 2009 and 2017. We excluded participants who were hospitalized at institutions that lacked cardiology services (n=246). We examined nine candidate SDOH, which align with the Healthy People 2030 conceptual model: Black race, social isolation (0-1 visits from a family or friend in the past month), social network/caregiver availability (having someone to care for them if ill), educational attainment < high school, annual household income < $35,000, living in rural areas, living in a zip code with high poverty, living in a Health Professional Shortage Area, and residing in a state with poor public health infrastructure. The primary outcome was cardiologist involvement, a binary variable which was defined as involvement of a cardiologist as the primary responsible clinician or as a consultant, collected via chart review. We examined associations between each SDOH and cardiologist involvement using Poisson regression with robust standard errors. Candidate SDOH with statistically significant associations (p<0.10) were retained for multivariable analysis. Potential confounders/covariates for the multivariable analysis included age, race, sex, HF characteristics, comorbidities, and hospital characteristics.

Results

We examined 876 participants hospitalized at 549 unique US hospitals. The median age was 77.5 years (IQR 71.0-83.7), 45.9% were female, 41.4% were Black, and 56.2% had low income. Low household income (<$35,000/year) was the only SDOH that had a statistically significant association with cardiologist involvement in a bivariate analysis (RR: 0.88 [95% CI: 0.82-0.95]). After adjusting for potential confounders, low income remained inversely associated (RR: 0.89 [95% CI: 0.82-0.97]).

Conclusions

Adults with low household income were 11% less likely to have a cardiologist involved in their care during a hospitalization for HF. This suggests that socioeconomic status may implicitly bias the care provided to patients hospitalized for HF.

Introduction of a new scoring tool to identify clinically stable heart failure patients

Introduction

Heart failure (HF) poses a burden on specialist care, making referral of clinically stable HF patients to primary care a desirable goal. However, a structured approach to guide patient referral is lacking.

Methods

The Maastricht Instability Score—Heart Failure (MIS-HF) questionnaire was developed to objectively stratify the clinical status of HF patients: patients with a low MIS-HF (0–2 points, indicating a stable clinical condition) were considered for treatment in primary care, whereas high scores (> 2 points) indicated the need for specialised care. The MIS-HF was evaluated in 637 consecutive HF patients presenting between 2015 and 2018 at Maastricht University Medical Centre.

Results

Of the 637 patients, 329 (52%) had a low score and 205 of these 329 (62%) patients were referred to primary care. The remaining 124 (38%) patients remained in secondary care. Of the 308 (48%) patients with a high score (> 2 points), 265 (86%) remained in secondary care and 41 (14%) were referred to primary care. The primary composite endpoint (mortality, cardiac hospital admissions) occurred more frequently in patients with a high compared to those with a low MIS-HF after 1 year of follow-up (29.2% vs 10.9%; odds ratio (OR) 3.36, 95% confidence interval (CI) 2.20–5.14). No significant difference in the composite endpoint (9.8% vs 12.9%; OR 0.73, 95% CI 0.36–1.47) was found between patients with a low MIS-HF treated in primary versus secondary care.

Conclusion

The MIS-HF questionnaire may improve referral policies, as it helps to identify HF patients that can safely be referred to primary care.

Supplementary Information

The online version of this article (10.1007/s12471-021-01654-8) contains supplementary material, which is available to authorized users.

Impact of Board-Certified Cardiologist Characteristics on Risk of In-Hospital Mortality

Background: This study examined the influence of board-certified cardiologist characteristics on the in-hospital mortality of patients with cardiovascular disease.

Methods and Results: Data were collected between 2012 and 2014 from a nationwide database of acute care hospitals in Japan. Overall, there were 1,422,703 patients, of whom 883,746 were analyzed. The primary outcome was all-cause in-hospital mortality. The association between board-certified cardiologist characteristics and in-hospital mortality was estimated using multilevel mixed-effect logistic regression modeling. Median age of cardiologists in a hospital was not related to in-hospital mortality (OR, 1.003; 95% CI: 0.998–1.008, P=0.316), but a greater cardiologist age range was associated with a lower risk of in-hospital mortality (OR, 0.992; 95% CI: 0.988–0.995 per 1-unit increment in age range, P<0.001). Meanwhile, the average years of experience of the board-certified cardiologists in a hospital was not associated with a lower risk of in-hospital mortality (OR, 1.002; 95% CI: 0.996–1.007, P=0.525), but a greater range of years of experience was (OR, 0.986; 95% CI: 0.983–0.990 per 1-unit increment in range of years of experience, P<0.001).

Conclusions: Median board-certified cardiologist age/experience at an institution is not related to in-hospital mortality, but a greater range in age/experience is associated with a lower risk of mortality.

Number of Cardiologists per Cardiovascular Beds and In-Hospital Mortality for Acute Heart Failure: A Nationwide Study in Japan

Background

Little evidence is available about the number of cardiologists required for appropriate treatment of heart failure (HF). Our objective was to determine the association between the number of cardiologists per cardiology beds for treating patients with acute HF and in‐hospital mortality.

Methods and Results

This was a cross‐sectional study, and we used the Japanese Registry of All Cardiac and Vascular Diseases Diagnosis Procedure Combination discharge database. The data of patients with HF on emergency admission from April 1, 2012, to March 31, 2014, were extracted. The patients were categorized into 4 groups by the quartiles of the numbers of cardiologists per 50 cardiovascular beds (first group: median, 4.4 [interquartile range, 3.5–5.0]; second group: median, 6.7 [interquartile range, 6.5–7.5]; third group: median, 9.7 [interquartile range, 8.8–10.1]; and fourth group: median, 16.7 [interquartile range, 14.0–23.8]). Using multilevel mixed‐effect logistics regression, we determined adjusted odds ratios for in‐hospital mortality. We identified 154 290 patients with HF on emergency admissions. There were 29 626, 36 587, 46 451, and 41 626 patients in the first, second, third, and fourth groups, respectively. HF severity, on the basis of New York Heart Association classification, was similar in the 3 groups. Adjusted odds ratios (95% CIs) for in‐hospital mortality were 0.92 (0.82–1.04; P=0.20), 0.82 (0.72–0.92; P<0.001), and 0.70 (0.61–0.80; P<0.001) for the second, third, and fourth groups, respectively. The proportion of medication used, including angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers, β blockers, and mineralocorticoid receptor antagonists, was positively correlated to the number of cardiologists.

Conclusions

Patients hospitalized for HF in hospitals with larger numbers of cardiologists per cardiovascular beds had lower 30‐day mortality.

Improving Provider Adherence to Guideline Recommendations in Heart Failure

PURPOSE OF REVIEW

Heart failure clinical practice guidelines are fundamental and serve as framework for providers to deliver evidence-based care that correlates with enhanced patient outcomes. However, adherence, particularly to guideline-directed medical therapy, remains suboptimal for a multitude of reasons.

RECENT FINDINGS

Despite robust clinical trials, updated guidelines and an expert consensus statement from American Heart Association, American College of Cardiology, and Heart Failure Society of America registry data signal that heart failure patients do not receive appropriate pharmacotherapy and may receive an intracardiac device without prior initiation or optimization of medical therapy. Strategies to improve provider adherence to heart failure guidelines include multidisciplinary models and appropriate referral and care standardization. These approaches can improve morbidity, mortality, and quality of life in HF patients.

Medical therapy doses at hospital discharge in patients with existing and de novo heart failure

AIMS

Uptitrating angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACE-I/ARBs), beta-blockers, and mineralocorticoid receptor antagonists (MRAs) to optimal doses in heart failure with reduced ejection fraction (HFrEF) is associated with improved outcomes and recommended in guidelines. Studies of ambulatory patients found that a minority are prescribed optimal doses. However, dose at hospital discharge has rarely been reported. This information may guide quality improvement initiatives during and following discharge.

METHODS AND RESULTS

We assessed 370 consecutive patients with HFrEF hospitalized at two centres in Vancouver, Canada. Of those without contraindications, 86.4%, 93.4%, and 44.7% were prescribed an ACE-I/ARB/sacubitril-valsartan, beta-blocker, or MRA, respectively. The proportion of eligible patients prescribed target dose was respectively 28.6%, 31.7%, and 4.1%. Forty-two of 248 eligible patients (16.9%) were prescribed ≥50% of target dose, and only three patients received target dosing of all three medication classes. In multivariate regression models, cardiologist involvement in care was independently associated with increased dose and prescription of ≥50% of target dose for all medications, whereas a history of HF was only predictive for beta-blockers.

CONCLUSIONS

In a single-region experience of hospitalized HFrEF patients, a high proportion of eligible patients were discharged on ACE-I/ARB or beta-blocker. Less than half were prescribed MRAs, and few were prescribed ≥50% or target dosing of all medications. Further exploration into barriers to medication uptitration, and improvement in processes of care, is needed.

Association of post-discharge specialty outpatient visits with readmissions and mortality in high-risk heart failure patients

Heart failure (HF) outcomes are especially poor in high-risk patients with certain comorbidities including diabetes mellitus (DM), chronic kidney disease (CKD), and chronic obstructive pulmonary disease (COPD). Whether early specialty or primary care provider (PCP) follow-up after HF discharge affects outcomes in high-risk patients is unknown.

METHODS

We analyzed patients discharged from a Get With The Guidelines HF-participating hospital from 2007-2012 with linked Medicare claims to investigate the association of medical specialist visit within 14 days of discharge stratified by comorbidity with the primary outcome of 90-day HF readmission. Secondary outcomes included 90-day and 1-year all-cause mortality.

RESULTS

Out of 33,243 patients, 39.4% had DM, 19.8% had CKD, 30.0% had COPD, and 36.3% had no key comorbidity. Nephrologist visit in patients with CKD was associated with a 35% reduction in 90-day HF readmission (hazard ratio [HR] 0.65, 95% confidence interval [CI] 0.49-0.85). Pulmonologist visit in patients with COPD was associated with a 29% reduction in 90-day HF readmission (HR 0.71, 95% CI 0.55-0.91). In patients with no key comorbidity, PCP and Cardiologist visits were associated with decreased 90-day mortality (HR for PCP 0.79, 95% CI 0.66-0.94; HR for Cardiologist 0.78, 95% CI 0.63-0.96). In patients with DM, Endocrinologist visit was associated with a 42% reduction of 90-day mortality (HR 0.58, 95% CI 0.34-0.99).

CONCLUSIONS

Specialist and PCP visit in the immediate post-discharge period may improve 90-day HF readmission and mortality in certain high-risk groups of patients with HF.

Higher Diuretic Requirements in Acute Heart Failure With Admission Hyponatraemia Versus Normonatraemia

BACKGROUND

Diuretic requirements in patients with acute decompensated heart failure (ADHF) and hyponatraemia versus normonatraemia on admission has not been previously explored.

METHODS

The Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial dataset was utilised to examine the characteristics and diuretic requirements of patients with ADHF with hyponatraemia or normonatraemia on admission.

RESULTS

Patients with ADHF and admission hyponatraemia (n = 103, average Na 130.2 meq/L) had a higher degree of congestion evident in higher frequency of jugular venous distension (JVD) >12 cmH₂O (p = 0.007), 2+ lower extremity oedema (p = 0.001), and higher right atrial pressure (p = 0.007), compared with normonatraemic patients (n = 327, average Na 138.6 meq/L). Despite a similar baseline furosemide dose in both groups (median 200 mg), the hyponatraemia group received higher in-hospital furosemide (280 vs. 200 mg, in both groups, respectively, p < 0.001) which represented a higher percentage of furosemide utilisation relative to baseline, compared with the normonatraemia group (33% vs 0%, in both groups respectively, p = 0.007). With in-hospital diuresis, the Na level of hyponatraemic subjects started significantly increasing at discharge and up to 6 months after randomisation-all relative to baseline. Hyponatraemic patients had significantly lower systolic blood pressure (SBP) longitudinally at multiple time points compared with normonataremic patients, but it did not further decrease despite the higher furosemide dose in the former group.

CONCLUSION

Patients with ADHF and hyponatraemia on admission had a higher degree of congestion and required higher doses of furosemide, compared with normonatraemic subjects. The lower Na and SBP in this instance should not lead to withholding or minimising diuretic dosage which should rather be dictated by volume status.

Short-term outcomes of heart failure patients with reduced and preserved ejection fraction after acute decompensation according to the final destination after emergency department care

AIMS

To compare short-term outcomes after an episode of acute heart failure (AHF) in patients with reduced and preserved ejection fractions (HFrEF, < 40%; and HFpEF, > 49%; respectively) according to their destinations after emergency department (ED) care.

METHODS AND RESULTS

This secondary analysis of the EAHFE Registry (consecutive AHF patients diagnosed in 41 Spanish EDs) investigated 30-day all-cause mortality, in-hospital all-cause mortality, prolonged hospitalisation (> 7 days), and 30-day post-discharge ED revisit due to AHF, all-cause death, and combined endpoint (ED revisit/death) in 5829 patients with echocardiographically documented HFrEF and HfpEF (HFrEF/HFpEF: 1,442/4,387). Adjusted ratios were calculated for patients admitted to internal medicine (IM), short stay unit (SSU), and discharged from the ED without hospitalisation (DEDWH) and compared with those admitted to cardiology. For HFrEF, the only significant differences were lower in-hospital mortality (OR = 0.26; 95% CI 0.08-0.81; p = 0.021) and prolonged hospitalisation (OR = 0.07; 95% CI 0.04-0.13; p < 0.001) related to SSU admission. For HFpEF, IM admission had a higher post-discharge 30-day mortality (HR = 1.85; 95% CI 1.05-3.25; p = 0.033) and combined endpoint (HR = 1.24; 95% CI 1.01-1.64; p = 0.044); SSU admission had a lower in-hospital mortality (OR = 0.43; 95% CI 0.23-0.80; p = 0.008) and prolonged hospitalisation (OR = 0.17; 95% CI 0.13-0.23; p < 0.001) but a higher post-discharge 30-day combined endpoint (HR = 1.29; 95% CI 1.01-1.64; p = 0.041); and DEDDWH had a lower 30-day mortality (HR = 0.46; 95% CI 0.28-0.75; p = 0.002) but higher post-discharge ED revisit (HR = 1.62; 95% CI 1.31-2.00; p < 0.001).

CONCLUSION

While HFrEF patients have similar short-term outcomes irrespective of the destination after ED care for an AHF episode, HFpEF patients present worse short-term outcomes when managed by non-cardiology departments, despite adjustment for different clinical patient profiles. Reasons for this heterogeneous specialty-related performance should be investigated.

Improving kNowledge Transfer to Efficaciously RAise the level of Contemporary Treatment in Heart Failure (INTERACT-in-HF): Study protocol of a mixed methods study

Heart failure is a complex disease with poor outcome. This complexity may prevent care providers from covering all aspects of care. This could not only be relevant for individual patient care, but also for care organisation. Disease management programmes applying a multidisciplinary approach are recommended to improve heart failure care. However, there is a scarcity of research considering how disease management programme perform, in what form they should be offered, and what care and support patients and care providers would benefit most. Therefore, the Improving kNowledge Transfer to Efficaciously Raise the level of Contemporary Treatment in Heart Failure (INTERACT-in-HF) study aims to explore the current processes of heart failure care and to identify factors that may facilitate and factors that may hamper heart failure care and guideline adherence. Within a cross-sectional mixed method design in three regions of the North-West part of Europe, patients (n = 88) and their care providers (n = 59) were interviewed. Prior to the in-depth interviews, patients were asked to complete three questionnaires: The Dutch Heart Failure Knowledge scale, The European Heart Failure Self-care Behaviour Scale and The global health status and social economic status. In parallel, retrospective data based on records from these (n = 88) and additional patients (n = 82) are reviewed. All interviews were audiotaped and transcribed verbatim for analysis.

Hazards of Hospitalization for Ambulatory Care Sensitive Conditions among Older Women: Evidence of Greater Risks for African Americans and Hispanics

Hospitalization for Ambulatory Care Sensitive conditions (ACSH) has been widely accepted as an indicator of the accessibility and overall performance of primary health care. Previous studies have found conflicting evidence about ACSH disparities associated with race or ethnicity for older persons. This study estimates discrete-time ACSH hazards for women aged 69 or older, using longitudinal data with multivariate controls. Data are from the 1984 to 1990 Longitudinal Study of Aging, linked with Medicare claims. The multivariate results are adjusted for age, education, insurance and marital status, and other factors associated with health status and primary care access, and also for important indicators of need that include self-rated health, comorbidities, physical impairments, and previous hospitalizations. Many of these factors are permitted to vary across time for each individual, thus limiting measurement error. Results suggest that older African American and Hispanic women have markedly higher ACSH risks than older non-Hispanic white women.

Intensive care units with low versus high volume of myocardial infarction: clinical outcomes, resource utilization, and quality metrics

Background

The volume-outcome relationship associated with intensive care unit (ICU) experience with managing acute myocardial infarction (AMI) remains inadequately understood.

Methods and Results

Within a multicenter clinical ICU database, we identified patients with a primary ICU admission diagnosis of AMI between 2008 and 2010 to evaluate whether annual AMI volume of an individual ICU is associated with mortality, length-of-stay, or quality indicators. Patients were categorized into those treated in ICUs with low-annual-AMI volume (≤50th percentile, <2 AMI patients/month, n=569 patients) versus high-annual-AMI volume (≥90th percentile, ≥8 AMI patients/month, n=17 553 patients). Poisson regression and generalized estimating equation with negative binomial regression were used to calculate the relative risk (95% CI) for mortality and length-of-stay, respectively, associated with admission to a low-AMI-volume ICU. When compared with high-AMI-volume, patients admitted to low-AMI-volume ICUs had substantially more medical comorbidities, higher in-hospital mortality (11% versus 4%, P<0.001), longer hospitalizations (6.9±7.0 versus 5.0±5.0 days, P<0.001), and fewer evidence-based therapies for AMI (reperfusion therapy, antiplatelets, β-blockers, and statins). However, after adjustment for baseline patient characteristics, low-AMI-volume ICU was no longer an independent predictor of in-hospital mortality (relative risk 1.17 [0.87 to 1.56]) or hospital length-of-stay (relative risk 1.01 [0.94 to 1.08]). Similar findings were noted in secondary analyses of ICU mortality and ICU length-of-stay.

Conclusions

Admission to an ICU with lower annual AMI volume is associated with higher in-hospital mortality, longer hospitalization, and lower use of evidence-based therapies for AMI. However, the relationship between low-AMI-volume and outcomes is no longer present after accounting for the higher-risk medical comorbidities and clinical characteristics of patients admitted to these ICUs.

Characteristics affecting oral anticoagulant therapy choice among patients with non-valvular atrial fibrillation: a retrospective claims analysis

Background

Dabigatran is one of the three newer oral anticoagulants (OACs) recently approved in the United States for stroke prevention in non-valvular atrial fibrillation (NVAF) patients. The objective of this study was to identify patient, healthcare provider, and health plan factors associated with dabigatran versus warfarin use among NVAF patients.

Methods

Administrative claims data from patients with ≥2 NVAF medical claims in the HealthCore Integrated Research Database between 10/1/2009 and 10/31/2011 were analyzed. During the study intake period (10/1/2010 - 10/31/2011), dabigatran patients had ≥2 dabigatran prescriptions, warfarin patients had ≥2 warfarin and no dabigatran prescriptions, and the first oral anticoagulant (OAC) prescription date was the index date. Continuous enrollment for 12 months preceding (“pre-index”) and ≥ 6 months following the index date was required. Patients without pre-index warfarin use were assigned to the ‘OAC-naïve’ subgroup. Separate analyses were performed for ‘all-patient’ and ‘OAC-naïve’ cohorts. Multivariable logistic regression (LR) identified factors associated with dabigatran versus warfarin use.

Results

Of 20,320 patients (3,019 dabigatran and 17,301 warfarin) who met study criteria, 27% of dabigatran and 13% of warfarin patients were OAC-naïve. Among all-patients, dabigatran patients were younger (mean 67 versus 73 years, p < 0.001), predominantly male (71% versus 61%, p < 0.001), and more frequently had a cardiologist prescriber (51% versus 30%, p < 0.001) than warfarin patients. Warfarin patients had higher pre-index Elixhauser Comorbidity Index (mean: 4.3 versus 4.0, p < 0.001) and higher ATRIA bleeding risk score (mean: 3.0 versus 2.3, p < 0.001). LR results were generally consistent between all- and OAC-naïve patients. Among OAC-naïve patients, strongest factors associated with dabigatran use were prescriber specialty (OR = 3.59, 95% CI 2.68-4.81 for cardiologist; OR = 2.22, 95% CI 1.65-2.97 for other specialist), health plan type (OR = 1.47 95% CI 1.10-1.96 for preferred provider organization), and prior ischemic stroke (OR = 1.42, 95% CI 1.06-1.90). Older age decreased the probability of dabigatran use.

Conclusions

Beside patient characteristics, cardiology specialty of the prescribing physician and health plan type were the strongest factors associated with dabigatran use.

The impact of a heart failure educational program for physicians varies based upon physician specialty

BACKGROUND

Beta blocker (BB) doses are often suboptimal in heart failure (HF) management. Differences in BB management patterns may exist between physicians in family medicine (FM) and internal medicine (IM). The aims of this study were to compare: 1) BB doses and prescription patterns; and 2) health care utilization rates in patients cared for by all primary care physicians compared to an historical control group after an educational program on HF management. A subgroup analysis was performed between patients cared for by FM and IM physicians. A secondary aim was to assess physician knowledge scores and satisfaction.

METHODS

A historically controlled study was conducted among low-income, underserved HF patients (mean age 54.1 ± 13.1, males 70%, mean ejection fraction 28.2 ± 9.8%). Statistical methods included linear mixed models and Fisher's exact tests to assess prescription patterns of BB dosing and health care utilization rates (all cause and HF related hospitalizations, emergency department use and clinic visits).

RESULTS

Among 135 patients (experimental N = 81 and control N = 54), a linear mixed model test of group by time interaction showed no difference in BB dosage (t = -0.12, P = 0.91). FM physicians prescribed significant changes in BB doses compared to IM physicians (P = 0.04), had higher numbers of clinic visits (P = 0.03) and reported greater satisfaction with the program.

CONCLUSIONS

There was no difference in BB titration rates following an HF training intervention for physicians compared to historical controls. However, FM physicians had a greater change in prescribing practices compared to IM physicians. Educational programs targeting FM physicians may benefit HF patients and could potentially lead to greater adherence to clinical guidelines related to BB use and address gaps in providing HF care.

A multicenter prospective comparative effectiveness study of the effect of physician certification and center accreditation on patient-centered outcomes in obstructive sleep apnea

OBJECTIVES

To study the effect of sleep center accreditation and Sleep Medicine board certification of physicians on patient-centered outcomes in obstructive sleep apnea (OSA).

DESIGN

Prospective, multicenter, comparative effectiveness study.

SETTING

Four sleep centers.

PATIENTS

502 patients with OSA.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Patients at two accredited and two non-accredited centers underwent polysomnography at participating locations and completed validated questionnaires, with objective measurement of positive airway pressure (PAP) therapy adherence performed three months after therapy initiation. The proportion of patients (age 53 ± 13[SD] years; 26% women; and body mass index 33.6 ± 7.2 kg/m(2)) who were adherent to PAP therapy by Medicare guidelines (> 70% of nights with ≥ 4 h use over a 30-day period) was greater in accredited (79%) than non-accredited sites (64%; p = 0.004). After adjustment for confounding variables, patients who received care from accredited centers (odds ratio [OR] 2.2, 95% confidence interval [CI], 1.2-4.2; p = 0.016) and certified physicians (OR 2.3, 95% CI, 1.3-4.0; p = 0.005) were more likely to be adherent to PAP therapy than those who received care from non-accredited centers and non-certified physicians. Patient satisfaction was associated with greater education received from physician (OR 4.6; 95% CI 2.3-9.3); greater risk perception (OR 2.7; 95% CI 1.0-7.4); physician certification (OR 2.1; 95% CI 1.1-4.2); and inversely related to delays in care (OR 0.5; 95% CI 0.3-0.9; p < 0.05). Such delays were inversely related to accreditation-certification status (p < 0.0001).

CONCLUSIONS

In patients with OSA, accreditation-certification status of sleep centers and physicians was associated with better PAP adherence, better patient education, better patient satisfaction, and greater timeliness.

COMMENTARY

A commentary on this article appears in this issue on page 251.

CITATION

Parthasarathy S; Subramanian S; Quan SF. A multicenter prospective comparative effectiveness study of the effect of physician certification and center accreditation on patient-centered outcomes in obstructive sleep apnea.

'Soft and fluffy': medical students' attitudes towards psychology in medical education

Psychology is viewed by medical students in a negative light. In order to understand this phenomenon, we interviewed 19 medical students about their experiences of psychology in medical education. Interviews were transcribed verbatim and analysed using thematic analysis. Four main themes were generated: attitudes, teaching culture, curriculum factors and future career path; negative attitudes were transmitted by teachers to students and psychology was associated with students opting for a career in general practice. In summary, appreciation of psychology in medical education will only happen if all educators involved in medical education value and respect each other's speciality and expertise.

Physician volume, specialty, and outcomes of care for patients with heart failure

BACKGROUND

There is an urgent need to improve outcomes and reduce costs for patients with heart failure (HF). Physician volume is associated with better outcomes for patients undergoing procedures, but its association with outcomes for medically managed diseases, such as HF, is not well understood.

METHODS AND RESULTS

We used Medicare inpatient data in 2009 to examine all HF admissions to acute care hospitals in the United States. We divided physicians into quintiles according to their volume of patients with HF. We used patient-level regression to compare 30-day risk-adjusted mortality, readmissions, and costs across volume groups, controlling for patient, physician, and hospital characteristics. We examined physician volume within strata of hospital volume and physician specialty. Patients cared for by the high-volume physicians had lower mortality than those by the low-volume physicians (8.9% versus 9.7%; P<0.001); this relationship was strongest in low-volume hospitals. In contrast, patients cared for by high-volume physicians had higher readmission rates (25.8% versus 21.5%; P<0001); this relationship was similar across hospital volume groups. Finally, costs were higher for the high-volume physicians ($8982 versus $8731; P=0.002, a difference that was consistent across hospital volume groups). The relationship between physician volume and mortality was strongest for internists (9.2% versus 10.6%; P<0.001) and weakest for cardiologists (6.4% versus 6.7%; P=0.485).

CONCLUSIONS

Physician volume is associated with lower mortality for HF, particularly in low-volume institutions and among noncardiologist physicians. Our findings suggest that clinician expertise may play an important role in HF care.

Improved survival in patients with chronic mild/moderate systolic heart failure followed up in a specialist clinic

OBJECTIVE

To relate therapeutic issues, comorbidities and functional parameters to mortality/morbidity of mild/moderate heart failure patients.

METHODS

From our heart failure clinic, 372 heart failure patients (269 men, aged 66 ± 11 years), with stable heart failure and ejection fraction 45% or less were recruited. Survival curves were estimated according to the Kaplan-Meier method. Associations of protective/risk factors with cardiovascular mortality/morbidity were also evaluated.

RESULTS

One hundred and two patients (27%) died (aged 70 ± 10 years at diagnosis, 76 ± 10 at death) during follow-up (overall mortality at 60 months: 19.2%; mean follow-up period: 67 ± 44 months). Cardiovascular deaths were 64 (63% of total deaths, 44 men, age at diagnosis 70 ± 9). Cardiovascular mortality at 60 months was 12%; standardized mortality ratio was 5.9 for women and 6.8 for men. The remaining 38 patients (37% of total deaths, 30 men, age at diagnosis 70 ± 10) died of noncardiovascular causes. Overall, noncardiovascular mortality at 60 months was 7.2%; mean survival time from diagnosis to death was 63 ± 69 months (median 42, Q1 = 27.5, Q3 = 77.7). Average cardiovascular admission rate was 1.63 ± 1.84 admissions/patient. At multivariate analysis, only previous history of myocardial infarction [hazard ratio: 3.62 (1.70-7.73)], class of ejection fraction at diagnosis [hazard ratio: 0.36 (0.32-0.60)], acute cardiac decompensation at any time [hazard ratio: 1.55 (1.32-1.84)], implanted defibrillator [hazard ratio: 0.11 (0.01-0.83)] and use of statins [hazard ratio: 0.08 (0.007-0.42)] were independently associated with cardiovascular mortality. Factors associated to higher annual cardiovascular morbidity were age at diagnosis, chronic renal failure, diabetes, cardiac decompensation at any time, female sex and diuretic therapy. Angiotensin-converting enzyme (ACE) inhibitors and/or angiotensin-receptor-blockers reduced annual cardiovascular morbidity.

CONCLUSION

Survival in mild/moderate heart failure patients has consistently improved. Further improvements are warranted in terms of morbidity reduction.

Comparison of processes of care and clinical outcomes for patients newly hospitalized for heart failure attended by different physician specialists

BACKGROUND

Previous studies suggest that patients with heart failure (HF) treated by cardiologists have improved outcomes compared with patients treated by other physicians. It remains unclear whether these findings reflect differences in patient characteristics, processes of care, practice setting, or a combination of these factors.

METHODS

We examined physician specialty-related differences in processes of care and clinical outcomes for 7,634 patients newly hospitalized for HF in Ontario, Canada, who were included in the EFFECT study between April 2004 and March 2005. Patients were categorized according to whether they received cardiologist, generalist (e.g., internist or family doctor), or generalist care with cardiology consultation.

RESULTS

Multivariable hierarchical modeling demonstrated that patients treated by generalists alone had higher risk of 30-day (odds ratio [OR] 1.50, 95% CI 1.18-1.91) and 1-year mortality (OR 1.29, 95% CI 1.10-1.50), as well as the 1-year composite outcome of death and readmission, compared with patients treated by cardiologists. These differences were significantly attenuated if patients who had "do not resuscitate" orders were excluded. Patients who had a cardiologist involved in their care were more likely to undergo diagnostic procedures, such as echocardiography, and had higher rates of certain evidence-based pharmacologic therapy such as β-blockers.

CONCLUSION

Physician specialty-related differences in HF outcomes appear to reflect a combination of both case-mix differences and differences in the use of certain heart failure processes of care. These findings suggest that it may be possible to improve HF outcomes in patients receiving care from generalist physicians.

European Society of Cardiology Heart Failure Association Standards for delivering heart failure care

The management of heart failure (HF) is complex. As a consequence, most cardiology society guidelines now state that HF care should be delivered in a multiprofessional manner. The evidence base for this approach now means that the establishment of HF management programmes is a priority. This document aims to summarize the key elements which should be involved in, as well as some more desirable features which can improve the delivery of care in a HF management programme, while bearing in mind that the specifics of the service may vary from site to site. We envisage a situation whereby all patients have access to the best possible care, including improved access to palliative care services, informed by and responsive to advances in diagnosis management and treatment. The goal should be to provide a 'seamless' system of care across primary and hospital care so that the management of every patient is optimal, no matter where they begin or continue their health-care journey.

Improved outcomes with early collaborative care of ambulatory heart failure patients discharged from the emergency department

BACKGROUND

The type of outpatient physician care after an emergency department visit for heart failure may affect patients' outcomes.

METHODS AND RESULTS

Using the National Ambulatory Care Reporting System, we examined the care and outcomes of heart failure patients who visited and were discharged from the emergency department in Ontario, Canada (April 2004 to March 2007). Early collaborative care by a cardiologist and primary care (PC) physician within 30 days after discharge was compared with PC alone. Care for 10 599 patients (age, 74.9±11.9 years; 50.2% male) was provided by PC alone (n=6596), cardiologist alone (n=535), or concurrently by both cardiologist and PC (n=1478); 1990 did not visit a physician. Collaborative care patients were more likely to undergo assessment of left ventricular function (57.4% versus 28.7%), noninvasive stress testing (20.1% versus 7.8%), and cardiac catheterization (11.6% versus 2.7%) compared with PC. Drug prescriptions (patients ≥65 years of age) demonstrated higher use of angiotensin-converting enzyme inhibitors (58.8% versus 54.6%), angiotensin receptor blockers (22.7% versus 18.1%), β-adrenoceptor antagonists (63.4% versus 48.0%), loop diuretics (84.2% versus 79.6%), metolazone (4.8% versus 3.4%), and spironolactone (19.8% versus 12.7%) within 100 days after emergency department discharge for collaborative care compared with PC. In a propensity-matched model, mortality was lower with PC compared with no physician visit (hazard ratio, 0.75; 95% confidence interval, 0.64 to 0.87; P<0.001). Collaborative care reduced mortality compared with PC (hazard ratio, 0.79; 95% confidence interval, 0.63 to 1.00; P=0.045). Sole cardiology care conferred a trend to increased mortality (hazard ratio, 1.41 versus collaborative care; 95% confidence interval, 0.98 to 2.03; P=0.067).

CONCLUSIONS

Early collaborative heart failure care was associated with increased use of drug therapies and cardiovascular diagnostic tests and better outcomes compared with PC alone.

[Continuity of medical care. Evaluation of a collaborative program between hospital and Primary Care]

The patients being treated in our health care system are becoming increasingly older and have a greater prevalence of chronic diseases. Due to these factors, these patients require greater and easier accessibility to the system as well as continuity of medical care. Collaboration between the different levels of health care has been instrumental in the success of the system and has produced changes in the hospital medical care protocol. Our hospital has developed a care model oriented towards the patient's needs, resulting in a higher grade of satisfaction among the medical professionals. In this paper, we have given a detailed description of part of our medical model, illustrating its different components and indicating several parameters of its evaluation. We have also reviewed the current state of the various models published on this topic. In summary, we believe that this medical care model presents a different approach to management that benefits patients, medical professionals and the health system alike.

Canadian Cardiovascular Society Consensus Conference guidelines on heart failure--2008 update: best practices for the transition of care of heart failure patients, and the recognition, investigation and treatment of cardiomyopathies

Heart failure is a clinical syndrome that normally requires health care to be provided by both specialists and nonspecialists. This is advantageous because patients benefit from complementary skill sets and experience, but can present challenges in the development of a common, shared treatment plan. The Canadian Cardiovascular Society published a comprehensive set of recommendations on the diagnosis and management of heart failure in January 2006, and on the prevention, management during intercurrent illness or acute decompensation, and use of biomarkers in January 2007. The present update builds on those core recommendations. Based on feedback obtained through a national program of heart failure workshops during 2006 and 2007, several topics were identified as priorities because of the challenges they pose to health care professionals. New evidence-based recommendations were developed using the structured approach for the review and assessment of evidence that was adopted and previously described by the Society. Specific recommendations and practical tips were written for best practices during the transition of care of heart failure patients, and the recognition, investigation and treatment of some specific cardiomyopathies. Specific clinical questions that are addressed include: What information should a referring physician provide for a specialist consultation? What instructions should a consultant provide to the referring physician? What processes should be in place to ensure that the expectations and needs of each physician are met? When a cardiomyopathy is suspected, how can it be recognized, how should it be investigated and diagnosed, how should it be treated, when should the patient be referred, and what special tests are available to assist in the diagnosis and treatment? The goals of the present update are to translate best evidence into practice, apply clinical wisdom where evidence for specific strategies is weaker, and aid physicians and other health care providers to optimally treat heart failure patients, resulting in a measurable impact on patient health and clinical outcomes in Canada.

Treating the right patient at the right time: access to specialist consultation and non-invasive testing

The Council of the Canadian Cardiovascular Society commissioned working groups to examine issues of access to, and wait times for, various aspects of cardiovascular care. The present article summarizes the deliberations on targets for medically acceptable wait times for access to cardiovascular specialist evaluation and on the performance of noninvasive testing needed to complete this evaluation. Three categories of referral indications were identified: those requiring hospitalization due to substantial ongoing risk of mortality and morbidity; those requiring an expedited early review in an ambulatory setting; and, finally, a larger category in which delays of two to six weeks can be justified. The proposed wait time targets will provide guidance on the timeliness of care to busy clinicians charged with the care of patients with cardiovascular disease, help policy makers appreciate the clinical challenges in providing access to high quality care, and highlight the critical need for a thoughtful review of cardiology human resource requirements. Wait time implementation suggestions are also included, such as the innovative use of disease management and special need clinics. The times proposed assume that available clinical practice guidelines are followed for clinical coronary syndrome management and for treatment of associated conditions such as hypertension, diabetes, renal disease, smoking cessation and lipid disorders. Although media attention tends to focus on wait times for higher profile surgical procedures and high technology imaging, it is likely that patients face the greatest wait-related risk at the earlier phases of care, before the disease has been adequately characterized.

Diabetes in heart failure: prevalence and impact on outcome in the population

PURPOSE

Little is known on the prevalence and prognostic importance of diabetes mellitus (DM) among individuals with heart failure (HF) in community-based cohorts.

METHODS

Within Olmsted County, Minnesota, a random sample of all subjects with a first diagnosis of HF between 1979 and 1999 was validated using Framingham criteria. DM was validated using glycemic criteria.

RESULTS

Among 665 subjects with HF (mean age 77+/-12 years, 46% male), 20% had prior DM. Subjects with DM were younger, had greater body mass index (BMI), and lower left ventricular ejection fraction than subjects without diabetes. The prevalence of DM increased markedly over time (3.8% per year; 95% confidence interval [CI], 0.8 to 6.9; P=.024), independently of BMI, particularly in older subjects (odds ratio of having DM in 1999 compared with 1979 was 3.93 [95% CI, 1.57 to 9.83] in subjects > or = 75 years vs. 1.11 [95% CI, .40 to 3.05] in subjects <75 years). Five-year survival was 37% among subjects with DM versus 46% among subjects without (P=.017). The risk of death associated with DM differed markedly according to clinical coronary artery disease (CAD) (P=.025). Subjects with DM and no CAD had a higher risk of death (relative risk [RR]=1.79 [95% CI, 1.33 to 2.41]) than those with CAD (RR=1.11 [95% CI, .81 to 1.51]), independently of age, sex, BMI, renal function, calendar year of HF, comorbidity and EF.

CONCLUSIONS

Among community-dwelling patients with HF, the prevalence of DM increased markedly over time. DM is associated with a large increase in mortality, particularly among subjects without clinical CAD, underscoring the importance of aggressive management of DM in HF.

Overview of acute decompensated heart failure in Argentina: lessons learned from 5 registries during the last decade

BACKGROUND

The acute decompensated heart failure (ADHF) is not as well characterized as the chronic phase, particularly in Latin American countries. Thus, the aim of this overview was to describe the clinical profile, treatment, and inhospital course of ADHF during the last decade in Argentina.

METHODS

Results obtained from 5 Argentinean prospective and multicenter registries, involving 2974 patients admitted for ADHF, were assessed. These registries were performed and published between 1992 and 2004.

RESULTS

The mean age was 65 to 70 years, and nearly 40% were female. Coronary artery disease was the main etiology in nearly 30% of the patients. Between 1992 and 2004, the use of angiotensin-converting enzyme inhibitors increased from 29.9% to 53.4% before admission and from 48.5% to 69.3% before discharge; the use of beta-blockers rose from 4.2% to 33.2% at admission and from 2.5% to 42.4% at predischarge (all P < .0001). Inhospital mortality rates in the first to the fifth registries were 12.1%, 4.6%, 10.5%, 8.9%, and 4.7% (P [trend] = .006). However, there were 98 (7.7%) deaths among 1272 patients before 2002, compared with 129 (7.6%) among 1702 since 2002 (P = .9).

CONCLUSIONS

The clinical profile of this largest sample of ADHF reported from a Latin American country is different from that observed in clinical trials and comparable to registries worldwide. Although an improvement in the use of recommended drugs was observed in the last decade, the average mortality has not changed. These findings might have implications in the design of multinational clinical trials.

Physician specialty and mortality among elderly patients hospitalized with heart failure

BACKGROUND

Whether specialty care improves survival among patients with heart failure remains controversial.

METHODS

We evaluated specialty care and outcomes in 25869 Medicare beneficiaries hospitalized with heart failure in the United States from 1998 through 1999. Patients were classified based on the specialty of their attending physician: cardiologist, internist, general physician, or family physician. The primary outcome of interest was all-cause mortality within 30 days of admission.

RESULTS

Cardiologists were attending physicians for 26%, internists for 50%, and general and family physicians cared for the remainder. Mortality at 30 days was lowest for patients cared for by cardiologists (8.8%), higher for patients cared for by internists (10.0%, relative risk [RR] = 1.07; 95% confidence interval [CI]: 0.97 to 1.19; P = 0.059) and general physicians (11.1%, RR = 1.26; 95% CI: 0.99 to 1.58; P = 0.086), and highest for patients cared for by family physicians (12.0%, RR = 1.31; 95% CI: 1.15 to 1.49; P <0.001). Patients cared for by family physicians remained at higher 30-day mortality rates whether with (RR = 1.30; 95% CI: 1.11 to 1.52) or without consultation with cardiologists (RR = 1.31; 95% CI: 1.13 to 1.52).

CONCLUSION

Hospitalized patients with heart failure had lower 30-day mortality when treated by cardiologists than when they were treated by other physicians. Although these differences were modest (RR = 1.07) for internists, they were substantial for general physicians (RR = 1.26) and family physicians (RR = 1.31); of note was that inpatient cardiology consultation did not appear to change this relation.

Temporal trends in survival and hospitalizations in outpatients with chronic systolic heart failure in 1995 and 1999

Abstract Background Community and hospital studies have suggested that survival of patients with heart failure (HF) has increased; however, the causes of the improvement and the hospital readmission rates remain undetermined. Methods and Results We compared survival and hospital admission rates in 2 cohorts enrolled in a national registry of outpatients with HF secondary to left ventricular (LV) systolic dysfunction referred to cardiology centers in 1995 (n = 712) and 1999 (n = 603). One year after enrollment, 163 of 1315 patients (12%) were dead. Survival rates were 85% in the 1995 versus 91% in the 1999 cohort. Older age, New York Heart Association (NYHA) class III-IV, anemia, hyponatremia, hypotension, and a lower LV ejection fraction (LVEF) were associated to an increased risk of all-cause mortality by multivariate analysis. Furthermore a significant independent cohort effect was observed: the adjusted risk of death was 1.30 (95% CI 1.16-1.45) for the 1995 versus 1999 cohort (survival difference adjusted P = .0067). The proportion of patients admitted to hospital declined significantly in 1999 versus 1995, for all causes (20% versus 27%, P = .006), for cardiac causes (16% versus 22%, P = .002), and for worsening congestive heart failure (8% versus 15%, P = .0005). Survival free from HF admission was 69% in 1995 versus 84% in 1999 (adjusted P = .0001); NYHA class III-IV, hypotension, diuretics and a lower LVEF were associated to an increased risk of this combined end point by multivariate analysis, as well as the enrollment year (relative risk 1.38, 95% CI 1.22-1.56, P = .0039). Conclusion In a national cardiologic registry of outpatients with systolic HF, survival improved and hospital admissions decreased over a 4-year period. These results underscore the importance of networking and the careful implementation of practice guidelines to elevate standards of care.

Impact of specialist follow-up in outpatients with congestive heart failure

BACKGROUND

There is uncertainty about whether physician specialty influences the outcomes of outpatients with congestive heart failure after adjustment for differences in case mix. Our objective was to determine the impact of physician specialty on outcomes in outpatients with new-onset congestive heart failure.

METHODS

The study was a population-based retrospective cohort study involving patients with new-onset congestive heart failure discharged from 128 acute care hospitals in Alberta between Apr. 1, 1998, and July 1, 2000. Outcomes were resource utilization (clinic visits, emergency department visits and hospital admissions) and survival at 30 days and 1 year.

RESULTS

A total of 3136 patients were discharged from hospital with a new diagnosis of congestive heart failure (median age 76 years, 50% men). Of these, 1062 (34%) received no follow-up visits for cardiovascular care, 738 (24%) were seen by a family physician (FP) alone, 29 (1%) by a specialist (cardiologist or general internist) alone and 1307 (42%) by both a specialist and an FP. Compared with patients who received no follow-up cardiovascular care, patients who received regular cardiovascular follow-up visits with a physician had fewer visits to the emergency department (38% v. 80%), fewer were admitted to hospital (13% v. 94%), and the adjusted 1-year mortality was lower (22% v. 37%) (all p < 0.001). Compared with patients who received combined specialist and FP care, patients cared for exclusively by FPs had fewer outpatient visits (median 9 v. 17 in the first year), fewer of these patients presented to the emergency department (24% v. 45% in the first year), and fewer were readmitted for cardiovascular care (7% v. 16%) (all p < 0.001). However, the adjusted mortality at 1 year was lower among patients treated with combined care (17% v. 28%, p < 0.001) despite a higher burden of comorbidities. In a multivariate model adjusting for comorbidities (with no cardiovascular follow-up visits as the reference category), the mortality was lower among patients followed on an outpatient basis by an FP alone (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.53-0.82) or by an FP and a specialist (OR 0.34, 95% CI 0.28-0.42). In a proportional hazards model with time-dependent covariates (with adjustment for frequency of follow-up visits), the risk of all-cause mortality was reduced significantly (hazard ratio 0.98, 95% CI 0.97- 0.99) with each specialist visit compared with FP care alone.

INTERPRETATION

Patients with congestive heart failure followed by both specialists and FPs had significantly better survival than those followed by FPs alone (or those who received no specific cardiovascular follow-up care). Methods to improve timely and appropriate access to specialists and to improve collaborative care structures are needed.

State of the science: posthospitalization nursing interventions in congestive heart failure

Nursing's role as key healthcare providers who give emotional support and teach self-care to patients with congestive heart failure has evolved substantially in recent years. The purpose of this article is to provide a systematic evaluation of the impact of posthospital nursing interventions in the management of heart failure. Four models of nursing interventions emerged: home-based nursing interventions, multidisciplinary interventions, heart failure clinics, and telephone- or technology-based nursing interventions. On the basis of currently available data, posthospital nursing interventions in congestive heart failure can improve clinical outcomes and decrease healthcare costs and resource use.

Telecardiology for patients with chronic heart failure: the 'SHL' experience in Israel

BACKGROUND

Patients with chronic heart failure characteristically have multiple hospital admissions for symptom control, deleteriously affecting their quality of life and imposing a burden on national healthcare costs. We assessed the effect of a novel transtelephonic monitoring and follow-up program on the admission rate and length of hospital stay as well as changes in their subjectively rated quality of life of patients with chronic heart failure.

METHODS

This prospective 1-year study was conducted on compliant subscribers to 'SHL', a telecardiological service with >60,000 subscribers, who were admitted > or = 2 times during the previous year for recurrent pulmonary edema or deterioration in heart failure. Their heart rate, blood pressure and body weight measurements were now automatically transmitted daily to 'SHL"s data bank and added to stored and updated medical records. A questionnaire survey acquired information on their quality of life.

RESULTS

The study cohort included 118 patients, mean age 75 years (range 49-89 years), 65% males, a II-IV class functional capacity and a 25% (range 10-39%) mean ejection fraction. There was a 66% reduction in the total hospitalization days (from 1623 in the year preceding study entry to 558 during the study period, p<0.0001). Although only 38/118 patients were hospitalized, most participants reported a significant subjective improvement in their quality of life.

CONCLUSIONS

Data are provided to demonstrate that a transtelephonic system allowing primary care at the patient's home can significantly reduce hospitalization rate and length of stay and significantly enhance the quality of life of patients with chronic heart failure.

Association between physician specialty and volumes of treated patients and mortality among patients hospitalized for newly diagnosed heart failure

PURPOSE

To assess the effects of hospital care by a specialist or nonspecialist physician, and by volume of treated patients, on mortality among hospitalized patients with newly diagnosed heart failure.

METHODS

Data describing heart failure patients in Alberta, Canada, from April 1, 1994, to March 31, 2000, were extracted from hospital abstracts and analyzed using hierarchical regression, with adjustment for patient demographic characteristics, comorbid conditions, physician volume, physician specialty, and hospital volume.

RESULTS

There were 16,162 hospital discharges for heart failure. Nonspecialist physicians were predominantly in the two lowest-volume quartiles (93%) and specialists were predominantly in the two highest-volume quartiles (68%). Considering the effects of volume alone and after adjustment for comorbidity, for each 10 additional hospital patients treated by a physician, the odds ratio for in-hospital mortality was 0.97 (95% confidence interval [CI]: 0.95 to 0.98), and the odds ratio for 1-year mortality was 0.99 (95% CI: 0.98 to 0.999). In analyses that considered both volume and specialty, the odds of in-hospital mortality decreased by 4% for each 10 additional in-hospital patients treated by a physician (odds ratio [OR] = 0.96; 95% CI: 0.95 to 0.98). In these same analyses, the odds ratio for in-hospital mortality was 1.32 (95% CI: 1.13 to 1.53) for general practitioners with specialist consultation and 1.32 (95% CI: 1.08 to 1.61) for specialists compared with general practitioners without specialist consultations. At 1 year, mortality was not associated significantly with the volume of in-hospital patients treated, or with the specialty of the treating physician.

CONCLUSION

Treatment by high-volume physicians during hospitalization for newly diagnosed heart failure was associated with a decrease in mortality, but these benefits did not persist at 1 year. The increased mortality noted in patients treated by specialists may be due to residual confounding or unmeasured comorbidity.

Evaluating hospital care for individuals with Alzheimer's disease using inpatient quality indicators

The purpose of this study was to determine whether persons with Alzheimer's disease (AD) were at greater risk for in-hospital mortality than non-AD patients as a result of poor quality of care. The study focused on six common medical conditions that result in hospital mortality. Using 1995 to 2000 data from New York state (n = 7,021,065), analysts compared mortality risk for individuals with and without AD. Among men, adjusted odds of death were greater for those with AD for gastrointestinal (GI) hemorrhage (+52 percent), congestive heart failure (CHF) (+42 percent), hip fracture (+35 percent), and acute myocardial infarction (AMI) (+30 percent) (all p < .0001). Among women, AD did not affect risks for most conditions. The results of the study show that men with AD are at higher risk of hospital mortality for common medical conditions, which may indicate poor quality of care. Their risk of hospital death was greater than that of men without AD for AMI, CHF, hip fracture, and GI hemorrhage. Their risk was also greater than that of women with AD for CHF, pneumonia, hip fracture, and GI hemorrhage. With the exception of pneumonia, this risk difference notably exceeded the analogous difference between women and men without AD. Hospital staff should be alerted to greater mortality risk for men with AD, as this risk may indicate lower quality of care.

Beta-blocker therapy for heart failure outside the clinical trial setting: findings of a community-based registry

BACKGROUND

beta-Blockers reduce morbidity and mortality rates in heart failure (HF) clinical trials, but it is unknown whether these findings persist in the community setting.

METHODS

A registry was created to survey tolerability and outcomes during initiation and 1-year follow-up of beta-blocker treatment with carvedilol in patients with HF treated by cardiologists (CARD) and primary care physicians (PCP) in the community.

RESULTS

A total 4280 patients were enrolled (3121 by 259 CARD, 1159 by 129 PCP). Patient age averaged 67 +/- 13 years; 35% were women and 12% were black. The left ventricular ejection fraction averaged 31 +/- 12; New York Heart Association class was II-III in 86% and IV in 3%. Patients of PCP had higher left ventricular ejection fraction, were older, and more frequently were female, black, diabetic, hypertensive, and in New York Heart Association class III/IV. Minimal difficulty titrating carvedilol was noted by >80% of CARD and PCP. Significantly more CARD-treated patients reached carvedilol doses of 25 mg twice daily (49% vs 27%). Kaplan-Meier all-cause mortality rate was 8.5% at 1 year and did not differ between CARD-treated and PCP-treated patients (8.2% vs 9.3%, P =.254). At least one HF hospitalization occurred in 11% of patients during follow-up, compared with 28% in the preceding year.

CONCLUSIONS

Community-based physicians use carvedilol with success approaching that of clinical trials. Overall mortality rates and HF hospitalizations were in the same low range as in clinical trials. Thus, it appears that results of clinical trials with carvedilol for HF can be translated to the community setting.

Physician supply, physician diversity, and outcomes of primary health care for older persons in the United States

This study examines effects of physician supply and diversity on hospitalization for ambulatory care sensitive conditions (ACSH). Data are from 31 metropolitan areas in the 1984-1990 United States Longitudinal Study of Aging, and the Area Resource File. Discrete-time hazard models estimate ACSH risk. High ACSH risk may indicate problems with the accessibility or quality of primary care. Results show low supply areas have high risk. Adequate supply areas have significantly lower risk. Areas with greater supply have high risk, which may indicate supplier-induced hospitalization. Greater physician diversity reduces ACSH risk. Results support policies promoting physician placement in underserved areas, and those that educate minority physicians.

Suboptimal pharmacotherapeutic management of chronic stable angina in the primary care setting

PURPOSE

To assess the adequacy of symptomatic treatment for chronic stable angina among primary care patients who receive care from the Department of Veterans Affairs (VA).

METHODS

We conducted a cross-sectional analysis involving 7038 veterans with self-reported coronary heart disease who completed the Seattle Angina Questionnaire and who had made a primary care visit to one of seven VA general internal medicine clinics between May 1997 and January 2000. The main outcome measures included the anginal frequency scale of the questionnaire and receipt of prescriptions for antianginal medication in three classes (beta-blockers, calcium antagonists, and long-acting nitrates).

RESULTS

Seventy percent of the patients experienced angina or took sublingual nitroglycerin preparations two or fewer times per week. Of the 30% of patients with more frequent symptoms, 22% were receiving no antianginal medications and 33% were receiving only one class of antianginal medication. Of the patients with frequent angina who were prescribed medications, 18% were taking no medications at the recommended therapeutic dose and 50% were receiving only one class of antianginal medication at the recommended therapeutic dose.

CONCLUSION

A substantial proportion of patients with frequent episodes of chronic stable angina appeared to be receiving an inadequate antianginal regimen in terms of number of agents and dosages. While numerous studies have described inadequate treatment of asymptomatic conditions and risk factors, our results suggest similar deficiencies in addressing a serious and eminently treatable symptomatic problem.