Resource use and survival of patients hospitalized with congestive heart failure: differences in care by specialty of the attending physician. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

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.

Who should see the patient? on deviations from preferred patient-provider assignments in hospitals

In various organizations including hospitals, individuals are not forced to follow specific assignments, and thus, deviations from preferred task assignments are common. This is due to the conventional wisdom that professionals should be given the flexibility to deviate from preferred assignments as needed. It is unclear, however, whether and when this conventional wisdom is true. We use evidence on the assignments of generalist and specialists to patients in our partner hospital (a children's hospital), and generate insights into whether and when hospital administrators should disallow such flexibility. We do so by identifying 73 top medical diagnoses and using detailed patient-level electronic medical record (EMR) data of more than 4,700 hospitalizations. In parallel, we conduct a survey of medical experts and utilized it to identify the preferred provider type that should have been assigned to each patient. Using these two sources of data, we examine the consequence of deviations from preferred provider assignments on three sets of performance measures: operational efficiency (measured by length of stay), quality of care (measured by 30-day readmissions and adverse events), and cost (measured by total charges). We find that deviating from preferred assignments is beneficial for task types (patients' diagnosis in our setting) that are either (a) well-defined (improving operational efficiency and costs), or (b) require high contact (improving costs and adverse events, though at the expense of lower operational efficiency). For other task types (e.g., highly complex or resource-intensive tasks), we observe that deviations are either detrimental or yield no tangible benefits, and thus, hospitals should try to eliminate them (e.g., by developing and enforcing assignment guidelines). To understand the causal mechanism behind our results, we make use of mediation analysis and find that utilizing advanced imaging (e.g., MRIs, CT scans, or nuclear radiology) plays an important role in how deviations impact performance outcomes. Our findings also provide evidence for a "no free lunch" theorem: while for some task types, deviations are beneficial for certain performance outcomes, they can simultaneously degrade performance in terms of other dimensions. To provide clear recommendations for hospital administrators, we also consider counterfactual scenarios corresponding to imposing the preferred assignments fully or partially, and perform cost-effectiveness analyses. Our results indicate that enforcing the preferred assignments either for all tasks or only for resource-intensive tasks is cost-effective, with the latter being the superior policy. Finally, by comparing deviations during weekdays and weekends, early shifts and late shifts, and high congestion and low congestion periods, our results shed light on some environmental conditions under which deviations occur more in practice.

Randomized Controlled Trial Comparing a Multidisciplinary Intervention by a Geriatrician and a Cardiologist to Usual Care after a Heart Failure Hospitalization in Older Patients: The SENECOR Study

Background: The prognosis of older patients after a heart failure (HF) hospitalization is poor. Methods: In this randomized trial, we consecutively assigned 150 patients 75 years old or older with a recent heart failure hospitalization to follow-up by a cardiologist (control) or follow-up by a cardiologist and a geriatrician (intervention). The primary outcome was all-cause hospitalization at a one-year follow-up. Results: All-cause hospitalization occurred in 47 of 75 patients (62.7%) in the intervention group and in 58 of 75 patients (77.3%) in the control group (hazard ratio, 0.67; 95% confidence interval, 0.46 to 0.99; p = 0.046). The number of patients with at least one HF hospitalization was similar in both groups (34.7% in the intervention group vs. 40% in the control group, p = 0.5). There were a total of 236 hospitalizations during the study period. The main reasons for hospitalization were heart failure (38.1%) and infection (14.8%). Mortality was 24.7%. Heart failure was the leading cause of mortality (54.1% of all deaths), without differences between groups. Conclusions: A follow-up by a cardiologist and geriatrician in older patients after an HF hospitalization was superior to a cardiologist’s follow-up in reducing all-cause hospitalization in older patients. (Funded by Beca Primitivo de la Vega, Fundación MAPFRE. ClinicalTrials.gov number, NCT03555318).

Disparities in the characteristics and outcomes of patients hospitalized with acute decompensated heart failure admitted to internal medicine and cardiology departments: a single-centre, retrospective cohort study

Aims

Efforts are constantly made to decrease the rates of readmission after acute decompensated heart failure (ADHF). ADHF admissions to internal medicine departments (IMD) were previously associated with higher risk for readmission compared with those admitted to cardiology departments (CD). It is unknown if the earlier still applies after recent advancement in care over the last decade. This contemporary cohort compares characteristics and outcomes of ADHF patients admitted to IMD with those admitted to CD.

Methods and results

The data for this single‐centre, retrospective study utilized a cohort of 8332 ADHF patients admitted between 2007 and 2017. We compared patients' baseline characteristics and clinical and laboratory indices of patients admitted to CD and IMD with the outcome defined as 30 day readmission rate. In comparison with those admitted to CD, patients admitted to IMD (89.5% of patients) were older (79 [70–86] vs. 69 [60–78] years; P < 0.001) and had a higher incidence of co‐morbidities and a higher ejection fraction. Readmission rates at 30 days were significantly lower in patients admitted to CD (15.9% vs. 19.6%; P = 0.01). Conflicting results of three statistical models failed to associate between the admitting department and 30 day readmission (odds ratio for 30 day readmission in CD: forced and backward stepwise logistic regression 0.8, 95% confidence interval 0.65–0.97, P = 0.02; stabilized inverse probability weights model odds ratio 1.0, confidence interval 0.75–1.37, P = 0.96).

Conclusions

This contemporary analysis of ADHF patient cohort demonstrates significant differences in the characteristics and outcomes of patients admitted to IMD and CD. Thus, focusing strategies for readmission prevention in patients admitted to IMD may be beneficial.

Physician-level variation in clinical outcomes and resource use in inpatient general internal medicine: an observational study

Background

Variations in inpatient medical care are typically attributed to system, hospital or patient factors. Little is known about variations at the physician level within hospitals. We described the physician-level variation in clinical outcomes and resource use in general internal medicine (GIM).

Methods

This was an observational study of all emergency admissions to GIM at seven hospitals in Ontario, Canada, over a 5-year period between 2010 and 2015. Physician-level variations in inpatient mortality, hospital length of stay, 30-day readmission and use of ‘advanced imaging’ (CT, MRI or ultrasound scans) were measured. Physicians were categorised into quartiles within each hospital for each outcome and then quartiles were pooled across all hospitals (eg, physicians in the highest quartile at each hospital were grouped together). We report absolute differences between physicians in the highest and lowest quartiles after matching admissions based on propensity scores to account for patient-level variation.

Results

The sample included 103 085 admissions to 135 attending physicians. After propensity score matching, the difference between physicians in the highest and lowest quartiles for in-hospital mortality was 2.4% (95% CI 0.6% to 4.3%, p<0.01); for readmission was 3.3% (95% CI 0.7% to 5.9%, p<0.01); for advanced imaging was 0.32 tests per admission (95% CI 0.12 to 0.52, p<0.01); and for hospital length of stay was 1.2 additional days per admission (95% CI 0.5 to 1.9, p<0.01). Physician-level differences in length of stay and imaging use were consistent across numerous sensitivity analyses and stable over time. Differences in mortality and readmission were consistent across most sensitivity analyses but were not stable over time and estimates were limited by sample size.

Conclusions

Patient outcomes and resource use in inpatient medical care varied substantially across physicians in this study. Physician-level variations in length of stay and imaging use were unlikely to be explained by patient factors whereas differences in mortality and readmission should be interpreted with caution and could be explained by unmeasured confounders. Physician-level variations may represent practice differences that highlight quality improvement opportunities.

Comparison of specialist and generalist care

Objective The choice of whether to admit under a specialist or a generalist unit is often made with neither clear rationale nor understanding of its consequences. The present study compared the characteristics and outcomes of patients admitted with community-acquired pneumonia to either a general medicine or respiratory unit. Methods This study was a retrospective cross-sectional study using data from public hospitals in Adelaide, South Australia. Over 5 years there were 9775 overnight, unplanned appropriate adult admissions. Patient length of hospital stay, in-patient mortality rate and 30-day unplanned readmission rate were calculated, with and without adjustment for patient age and comorbidity burden. Results Over 80% of these patients were cared for by a general medicine unit rather than a specialist unit. Patients admitted to a general medicine unit were, on average, 4 years older than those admitted to a respiratory unit. Comorbidity burdens were similar between units at the same hospital. Length of in-patient stay was >1 day shorter for those admitted to a general medicine unit, without significant compromise in mortality or readmission rates. Between each hospital, general medicine units showed a range of mortality rates and length of hospital stay, for which there was no obvious explanation. Conclusions Compared with speciality care, general medicine units can safely and efficiently care for patients presenting to hospital with community-acquired pneumonia. What is known about the topic? Within the narrow range of any specific disease, generalist medical services are often cited as inferior in performance compared with a speciality service. This has implications for hospital resourcing, including both staffing and ward allocation. What does this paper add? This paper demonstrates that most patients admitted with a principal diagnosis of community-acquired pneumonia were admitted to a generalist unit and did not apparently fare worse than patients admitted to a specialist service; patients admitted to a generalist unit spent less time in hospital and there was no difference in mortality or readmission rate compared with patients admitted to a specialist service. What are the implications for practitioners? The provision of generalist services at urban hospitals in Australia provides a safe alternative admission option for patients presenting with pneumonia, and possibly for other common acute medical conditions.

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.

Systematic review of economic burden of heart failure

The aim of this study is to perform a systematic review of the costing methodological approaches adopted by published cost-of-illness (COI) studies. A systematic review was performed to identify cost-of-illness studies of heart failure published between January 2003 and September 2015 via computerized databases such as Pubmed, Wiley Online, Science Direct, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Costs reported in the original studies were converted to 2014 international dollars (Int$). Thirty five out of 4972 studies met the inclusion criteria. Nineteen out of the 35 studies reported the costs as annual cost per patient, ranging from Int$ 908.00 to Int$ 84,434.00, while nine studies reported costs as per hospitalization, ranging from Int$ 3780.00 to Int$ 34,233.00. Cost of heart failure increased as condition of heart failure worsened from New York Heart Association (NYHA) class I to NYHA class IV. Hospitalization cost was found to be the main cost driver to the total health care cost. The annual cost of heart failure ranges from Int$ 908 to Int$ 40,971 per patient. The reported cost estimates were inconsistent across the COI studies, mainly due to the variation in term of methodological approaches such as disease definition, epidemiological approach of study, study perspective, cost disaggregation, estimation of resource utilization, valuation of unit cost components, and data sources used. Such variation will affect the reliability, consistency, validity, and relevance of the cost estimates across studies.

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.

Exploring the Validity of Developing an Interdisciplinarity Score of a Patient's Needs: Care Coordination, Patient Complexity, and Patient Safety Indicators

Despite the Affordable Care Act's push to improve the coordination of care for patients with multiple chronic conditions, most measures of coordination quality focus on a specific moment in the care process (e.g., medication errors or transfer between facilities), rather than patient outcomes. One possible supplementary way of measuring the care coordination quality of a facility would be to identify the patients needing the most coordination, and to look at outcomes for that group. This paper lays the groundwork for a new measure of care coordination quality by outlining a conceptual framework that considers the interaction between a patient's interdisciplinarity, biological susceptibility, and procedural intensity. Interdisciplinarity captures the degree of specialized medical expertise needed for a patient's care and will be an important measure to estimate the number of specialists a patient might see. We then develop a preliminary measure of interdisciplinarity and run tests linking interdisciplinarity to medical mistakes, as defined by Agency for Healthcare Research and Quality's Patient Safety Indicators. Finally, we use our preliminary measure to verify that interdisciplinarity is likely to be statistically different from existing measures of comorbidity, like the Charlson score. Future research will need to build upon our findings by developing a more statistically validated measure of interdisciplinarity.

Effect of cardiologist care on 6-month outcomes in patients discharged with heart failure: results from an observational study based on administrative data

OBJECTIVES

To evaluate the effect of cardiologist care on adherence to evidence-based secondary prevention medications, mortality and readmission within 6 months of discharge in patients with heart failure (HF).

DESIGN

Retrospective observational study based on administrative data.

SETTING

Local Healthcare Authority (LHA) of Bologna, one of the largest LHAs of Italy with ~870 000 inhabitants.

PARTICIPANTS

All patients residing in the LHA of Bologna discharged from hospital with a diagnosis of HF between 1 January 2015 and 31 December 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

Multivariable regression analysis was used to assess the association of inpatient and outpatient cardiologist care with adherence to evidence-based medications, all-cause mortality and hospital readmission (including emergency room visits) within 6 months of discharge.

RESULTS

The study population included 2650 patients (mean age 82.3 years). 340 (12.8%) patients were discharged from cardiology wards, while 635 (24.0%) were seen by a cardiologist during follow-up. Inpatient and outpatient cardiologist care was associated with an increased likelihood of adherence to ACE inhibitors/angiotensin receptor blockers (ACEIs/ARBs), β-blockers and aldosterone antagonists after discharge. The risk of mortality was significantly lower among patients adherent to ACEIs/ARBs and/or β-blockers (-53% and -28%, respectively); the risk of hospital readmission was significantly lower among patients adherent to ACEIs/ARBs (-28%).

CONCLUSIONS

Compared with non-specialist care, cardiologist care improves patient adherence to evidence-based medications and might thus favourably affect mortality and readmission following HF.

Cost-Effectiveness Analysis of Natriuretic Peptide Testing and Specialist Management in Patients with Suspected Acute Heart Failure

OBJECTIVES

To determine the cost-effectiveness of natriuretic peptide (NP) testing and specialist outreach in patients with acute heart failure (AHF) residing off the cardiology ward.

METHODS

We used a Markov model to estimate costs and quality-adjusted life-years (QALYs) for patients presenting to hospital with suspected AHF. We examined diagnostic workup with and without the NP test in suspected new cases, and we examined the impact of specialist heart failure outreach in all suspected cases. Inputs for the model were derived from systematic reviews, the UK national heart failure audit, randomized controlled trials, expert consensus from a National Institute for Health and Care Excellence guideline development group, and a national online survey. The main benefit from specialist care (cardiology ward and specialist outreach) was the increased likelihood of discharge on disease-modifying drugs for people with left ventricular systolic dysfunction, which improve mortality and reduce re-admissions due to worsened heart failure (associated with lower utility). Costs included diagnostic investigations, admissions, pharmacological therapy, and follow-up heart failure care.

RESULTS

NP testing and specialist outreach are both higher cost, higher QALY, cost-effective strategies (incremental cost-effectiveness ratios of £11,656 and £2,883 per QALY gained, respectively). Combining NP and specialist outreach is the most cost-effective strategy. This result was robust to both univariate deterministic and probabilistic sensitivity analyses.

CONCLUSIONS

NP testing for the diagnostic workup of new suspected AHF is cost-effective. The use of specialist heart failure outreach for inpatients with AHF residing off the cardiology ward is cost-effective. Both interventions will help improve outcomes for this high-risk group.

Prognostic Impact of Physician Specialty on the Prognosis of Outpatients With Heart Failure: Propensity Matched Analysis of the REDINSCOR and RICA Registries

INTRODUCTION AND OBJECTIVES

The specialty treating patients with heart failure (HF) has a prognostic impact in the hospital setting but this issue remains under debate in the ambulatory environment. We aimed to compare the clinical profile and outcomes of outpatients with HF treated by cardiologists or internists.

METHODS

We analyzed the clinical, electrocardiogram, laboratory, and echocardiographic data of 2 prospective multicenter Spanish cohorts of outpatients with HF treated by cardiologists (REDINSCOR, n=2150) or by internists (RICA, n=1396). Propensity score matching analysis was used to test the influence of physician specialty on outcome.

RESULTS

Cardiologist-treated patients were often men, were younger, and had ischemic etiology and reduced left ventricular ejection fraction (LVEF). Patients followed up by internists were predominantly women, were older, and a higher percentage had preserved LVEF and associated comorbidities. The 9-month mortality was lower in the REDINSCOR cohort (11.6% vs 16.9%; P<.001), but the 9-month HF-readmission rates were similar (15.7% vs 16.9%; P=.349). The propensity matching analysis selected 558 pairs of comparable patients and continued to show significantly lower 9-month mortality in the cardiology cohort (12.0% vs 18.8%; RR, 0.64; 95% confidence interval [95%CI], 0.48-0.85; P=.002), with no relevant differences in the 9-month HF-readmission rate (18.1% vs 17.2%; RR, 0.95; 95%CI, 0.74-1.22; P=.695).

CONCLUSIONS

Age, sex, LVEF and comorbidities were major determinants of specialty-related referral in HF outpatients. An in-depth propensity matched analysis showed significantly lower 9-month mortality in the cardiologist cohort.

Type of attending physician influenced feeding tube insertions for hospitalized elderly people with severe dementia

Striking variation has been documented in the rates of feeding tube insertion for hospitalized patients with advanced dementia. This occurs despite the harms of the procedure, which may outweigh its benefits, and the procedure's inconsistency with care focused on the patient's comfort. Among nursing home residents with advanced dementia who were hospitalized in 2001-10 with an infection or dehydration, we found that rates of insertion of a percutaneous endoscopic gastrostomy feeding tube varied by type of attending physician. Insertion rates were markedly lower when all of a patient's attending physicians were hospitalists (1.6 percent) or nonhospitalist generalists (2.2 percent), compared to all subspecialists (11.0 percent) or a mixture of physicians by type, which typically included a subspecialist (15.6 percent). The portion of patients seen by a mixture of attending physicians increased from 28.9 percent in 2001 to 38.3 percent in 2010. Efforts to improve decision making in the care of patients with advanced dementia should include interventions to improve communication among physicians and the education of subspecialists about the merits of using feeding tubes with this population.

Outcomes of patients with acute decompensated heart failure managed by cardiologists versus noncardiologists

Physician practice patterns in the management of hospitalized acute decompensated heart failure (ADHF) patients may vary by specialty; comparative practice patterns in ADHF management and clinical outcomes as a function of provider type have not been well reported. We studied a total of 496 patients discharged with the principal diagnosis of ADHF to analyze practice patterns among 3 provider types (cardiologists, hospitalists, and nonhospitalists). We examined outcomes of death and rehospitalization for HF and adherence to the Joint Commission HF performance core measures. Cardiologists had the highest adherence in all 4 HF core measures compared with hospitalists and nonhospitalists. At 6 months, 6.0% of the patients cared by cardiologists died compared with 10.9% and 11.4% cared by hospitalist and nonhospitalists (p = 0.12). Patients cared for by cardiologists had a significantly lower 6-month ADHF readmission rate (16.2%) compared with hospitalists (40.1%) and nonhospitalists (34.9%, p <0.001). In multivariate analysis, both hospitalist and nonhospitalist provider types were an independent predictor for 6-month ADHF-related readmission (hospitalists vs cardiologists, hazard ratioadjusted 3.01; 95% confidence interval 1.84 to 4.89, p <0.001; and nonhospitalists vs cardiologists, hazard ratioadjusted 2.07; 95% confidence interval 1.24 to 3.46, p = 0.005). In conclusion, cardiologist-delivered ADHF care is associated with greater adherence to HF core measures and with significantly lower rates of adverse outcome compared with noncardiologists.

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.

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.

Provider specialty and atrial fibrillation treatment strategies in United States community practice: findings from the ORBIT-AF registry

Background

The prevalence of atrial fibrillation (AF) continues to increase; however, there are limited data describing the division of care among practitioners in the community and whether care differs depending on provider specialty.

Methods and Results

Using the Outcomes Registry for Better Informed Treatment of AF (ORBIT‐AF) Registry, we described patient characteristics and AF management strategies in ambulatory clinic practice settings, including electrophysiology (EP), general cardiology, and primary care. A total of 10 097 patients were included; of these, 1544 (15.3%) were cared for by an EP provider, 6584 (65.2%) by a cardiology provider, and 1969 (19.5%) by an internal medicine/primary care provider. Compared with those patients who were cared for by cardiologists or internal medicine/primary care providers, patients cared for by EP providers were younger (median age, 73 years [interquartile range, IQR, 64, 80 years, Q1, Q3] versus 75 years [IQR, 67, 82 years] for cardiology and versus 76 years [IQR, 68, 82 years] for primary care). Compared with cardiology and internal medicine/primary care providers, EP providers used rhythm control (versus rate control) management more often (44.2% versus 29.7% and 28.8%, respectively, P<0.0001; adjusted odds ratio [OR] EP versus cardiology, 1.66 [95% confidence interval, CI, 1.05 to 2.61]; adjusted OR for internal medicine/primary care versus cardiology, 0.91 [95% CI, 0.65 to 1.26]). Use of oral anticoagulant therapy was high across all providers, although it was higher for cardiology and EP providers (overall, 76.1%; P=0.02 for difference between groups).

Conclusions

Our data demonstrate important differences between provider specialties, the demographics of the AF patient population treated, and treatment strategies—particularly for rhythm control and anticoagulation therapy.

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.

Procedure intensity and the cost of care

BACKGROUND

The intensive practice style of hospitals with high procedure rates may result in higher costs of care for medically managed patients. We sought to determine how costs for patients with heart failure (HF) not receiving procedures compare between hospital groups defined by their overall use of procedures.

METHODS AND RESULTS

We identified all 2009 to 2010 adult HF hospitalizations in hospitals capable of performing invasive procedures that had at least 25 HF hospitalizations in the Perspective database from Premier, Inc. We divided hospitals into 2 groups by the proportion of patients with HF receiving invasive percutaneous or surgical procedures: low (>0%-10%) and high (≥ 10%). The standard costs of hospitalizations at each hospital were risk adjusted using patient demographics and comorbidities. We used the Wilcoxon rank sum test to assess cost, length of stay, and mortality outcome differences between the 2 groups. Median risk-standardized costs among low-procedural HF hospitalizations were $5259 (interquartile range, $4683-$6814) versus $6965 (interquartile range, $5981-$8235) for hospitals with high procedure use (P<0.001). Median length of stay was 4 days for both groups. Risk-standardized mortality rates were 5.4% (low procedure) and 5.0% (high procedure) (P=0.009). We did not identify any single service area that explained the difference in costs between hospital groups, but these hospitals had higher costs for most service areas.

CONCLUSION

Among patients who do not receive invasive procedures, the cost of HF hospitalization is higher in more procedure-intense hospitals compared with hospitals that perform fewer procedures.

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.

In-hospital cardiology consultation and evidence-based care for nursing home residents with heart failure

OBJECTIVES

To determine the association between cardiology consultation and evidence-based care for nursing home (NH) residents with heart failure (HF).

PARTICIPANTS

Hospitalized NH residents (n = 646) discharged from 106 Alabama hospitals with a primary discharge diagnosis of HF during 1998-2001.

DESIGN

Observational. MEASUREMENTS OF EVIDENCE-BASED CARE: Preadmission estimation of left ventricular ejection fraction (LVEF) for patients with known HF (n = 494), in-hospital LVEF estimation for HF patients without known LVEF (n = 452), and discharge prescriptions of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEIs or ARBs) to systolic HF (LVEF <45%) patients discharged alive who were eligible to receive those drugs (n = 83). Eligibility for ACEIs or ARBs was defined as lack of prior allergy or adverse effect, serum creatinine lower than 2.5 mg/dL, serum potassium lower than 5.5 mEq/L, and systolic blood pressure higher than 100 mm Hg.

RESULTS

Preadmission LVEF was estimated in 38% and 12% of patients receiving and not receiving cardiology consultation, respectively (adjusted odds ratio [AOR], 3.49; 95% CI, 2.16-5.66; P < .001). In-hospital LVEF was estimated in 71% and 28% of patients receiving and not receiving cardiology consultation, respectively (AOR, 6.01; 95% CI, 3.69-9.79; P < .001). ACEIs or ARBs were prescribed to 62% and 82% of patients receiving and not receiving cardiology consultation, respectively (AOR, 0.24; 95% CI, 0.07-0.81; P = .022).

CONCLUSION

In-hospital cardiology consultation was associated with significantly higher odds of LVEF estimation among NH residents with HF; however, it did not translate into higher odds of discharge prescriptions for ACEIs or ARBs to NH residents with systolic HF who were eligible for the receipt of these drugs.

In-hospital management of heart failure: in 10 years we have improved, but not enough

It is well recognized that the majority of patients with heart failure (HF) are admitted to General Medicine Departments (GMDs), and that the recommendations of the international guidelines for the treatment of HF are often incorrectly applied in hospital practice. We evaluated the treatment of patients with HF discharged from a single hospital over a period of 10 years. The study population comprised two series of patients who were discharged from six GMDs of a single hospital with the diagnosis of HF in the first 2 months of 1998 and 2008. The patients were also divided in two groups on the basis of the type of HF, systolic or diastolic. In 10 years, the number of patients who were discharged with the diagnosis of HF increased, the median age rose from 79 to 82 years and diastolic has become the more common type of HF. The prevalence of comorbidities rose significantly. There was an increased use of ACE-inhibitors and betablockers, and a reduction of digoxin and nitrates. The mortality decreased from 16.7% in 1998 to 9.6% in 2008 (p < 0.02) and hospitalizations became shorter (p < 0.05) considering patients with systolic HF (EF ≤ 45%) the median age rose from 74 to 79 years old (p < 0.01). We recorded an increasing use of betablockers, a reduction in the prescription of digoxin. The percentage of Diastolic HF rose from 55.7% in 1998 to 65.0% in 2008 (p < 0.001). The median age of these patients changed from 79 to 82 years old (p < 0.05). In 10 years, the clinical characteristics and management of HF patients who are hospitalized have changed. Pharmacological treatment has improved, but it still remains far from being adequately compliant with guideline recommendations.

Influence of language barriers on outcomes of hospital care for general medicine inpatients

BACKGROUND

Few studies have examined whether patients with language barriers receive worse hospital care in terms of quality or efficiency.

OBJECTIVE

: To examine whether patients' primary language influences hospital outcomes.

DESIGN AND SETTING

Observational cohort of urban university hospital general medical admissions between July 1, 2001 to June 30, 2003.

PATIENTS

Eighteen years old or older whose hospital data included information on their primary language, specifically English, Russian, Spanish or Chinese.

MEASUREMENTS

Hospital costs, length of stay (LOS), and odds for 30-day readmission or 30-day mortality.

RESULTS

Of 7023 admitted patients, 84% spoke English, 8% spoke Chinese, 4% Russian and 4% Spanish. In multivariable models, non-English and English speakers had statistically similar total cost, LOS, and odds for mortality. However, non-English speakers had higher adjusted odds of readmission (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.0-1.7). Higher odds for readmission persisted for Chinese and Spanish speakers when compared to all English speakers (OR, 1.7; 95% CI, 1.2-2.3 and OR, 1.5; 95% CI, 1.0-2.3 respectively).

CONCLUSIONS

After accounting for socioeconomic variables and comorbidities, non-English speaking Latino and Chinese patients have higher risk for readmission. Whether language barriers produce differences in readmission or are a marker for less access to post-hospital care remains unclear. Journal of Hospital Medicine 2010;5:276-282. (c) 2010 Society of Hospital Medicine.

Specialty care use in US patients with chronic diseases

Despite efforts to eliminate health disparities, racial, ethnic, and geographic groups continue lag behind their counterparts in health outcomes in the United States. The purpose of this study is to determine variation in specialty care utilization by chronic disease status. Data were extracted from the Commonwealth Fund 2006 Health Care Quality Survey (n = 2475). A stratified minority sample design was employed to ensure a representative sample. Logistic regression was used in analyses to predict specialty care utilization in the sample. Poor perceived health, minority status, and lack of insurance was associated with reduced specialty care use and chronic disease diagnosis.

Differences in specialist consultations for cardiovascular disease by race, ethnicity, gender, insurance status, and site of primary care

BACKGROUND

Consultation with cardiologists may improve the quality of ambulatory care and reduce disparities for patients with heart disease. We assessed the use of cardiology consultations and the associated quality by race/ethnicity, gender, insurance status, and site of care.

METHODS AND RESULTS

In a retrospective cohort, we examined electronic records of 9761 adults with coronary artery disease or congestive heart failure (CHF) receiving primary care at practices affiliated with 2 academic medical centers during 2000 to 2005. During this period, 79.6% of patients with coronary artery disease and 90.3% of patients with CHF had a cardiology consultation. In multivariate analyses, women were less likely to receive a consultation than men for both conditions (coronary artery disease: hazard ratio, 0.89; 95% CI, 0.85 to 0.93; CHF: hazard ratio, 0.93; 95% CI, 0.87 to 0.99). Women also had 15% fewer follow-up consultations than men (P<0.001). Similarly, patients at community health centers were less likely to receive a consultation (coronary artery disease: hazard ratio, 0.79; 95% CI, 0.74 to 0.84; CHF: hazard ratio, 0.77; 95% CI: 0.71 to 0.84) and had 20% fewer follow-up consultations (P<0.001) relative to those at hospital-based practices. Black and Hispanic patients with CHF had 13% fewer follow-up consultations than white patients (P=0.01 and P=0.04, respectively). In adjusted analyses, consultation was associated with better processes of care compared with no consultation (P<0.001), particularly for women (P<0.001 for interaction between consultation and gender).

CONCLUSIONS

Among ambulatory patients with coronary artery disease or CHF, women and those at community health centers have less access to cardiologists. Consultation is associated with better quality of care and narrows the gender gap in quality.

Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are global epidemics incurring significant morbidity and mortality. The combination presents many diagnostic challenges. Clinical symptoms and signs frequently overlap. Evaluation of cardiac and pulmonary function is often problematic and occasionally misleading. Echocardiography and pulmonary function tests should be performed in every patient. Careful interpretation is required to avoid misdiagnosis and inappropriate treatment. Airflow obstruction, in particular, must be demonstrated when clinically euvolaemic. Very high and very low concentrations of natriuretic peptides have high positive and negative predictive values for diagnosing HF in those with both conditions. Intermediate values are less informative. Both conditions are systemic disorders with overlapping pathophysiological processes. In patients with HF, COPD is consistently an independent predictor of death and hospitalization. However, the impact on ischaemic and arrhythmic events is unknown. Greater collaboration is required between cardiologists and pulmonologists to better identify and manage concurrent HF and COPD. The resulting symptomatic and prognostic benefits outweigh those attainable by treating either condition alone.

Quality of care for decompensated heart failure: comparable performance between academic hospitalists and non-hospitalists

BACKGROUND

Hospitalists improve efficiency, but little information exists regarding whether they impact quality of care.

OBJECTIVE

To determine hospitalists' effect on the quality of acute congestive heart failure care.

DESIGN AND PARTICIPANTS

Using data from the Multicenter Hospitalist Study, we retrospectively evaluated quality of care in patients admitted with congestive heart failure who were assigned to hospitalists (n = 120) or non-hospitalists (n = 252) among six academic hospitals.

MEASUREMENTS

Quality measures included the percentage of patients who had ejection fraction (EF) measurement, received appropriate medications [i.e., angiotensin-converting enzyme inhibitor (ACE-I) or beta-blockers] at discharge, measures of care coordination (e.g., follow-up within 30 days), testing for cardiac ischemia (e.g., cardiac catheterization), as well as hospital length of stay, cost, and combined 30-day readmissions and mortality.

RESULTS

Compared to non-hospitalist physicians, hospitalists' patients had similar rates of EF measurement (85.3% vs. 87.5%; P = 0.57), ACE-I (91.5% vs. 88.0%; P = 0.52), or beta-blocker (46.9% vs. 42.1%; P = 0.57) prescriptions. Multivariable adjustment did not change these findings. Hospitalists' patients had higher odds of 30-day follow-up (adjusted OR = 1.83, 95% CI, 1.44 - 2.93). There were no significant differences between the groups' frequency of cardiac testing, length of stay, costs, or risk for readmission or death by 30-days.

CONCLUSION

Academic hospitalists and non-hospitalists provide similar quality of care for heart failure patients, although hospitalists are paying more attention to longitudinal care. Future efforts to improve quality of care in decompensated heart failure may require attention towards system-level factors.

Addressing the unit of analysis in medical care studies: a systematic review

OBJECTIVE

We assessed the frequency that patients are incorrectly used as the unit of analysis among studies of physicians' patient care behavior in articles published in high impact journals.

METHODS

We surveyed 30 high-impact journals across 6 medical fields for articles susceptible to unit of analysis errors published from 1994 to 2005. Three reviewers independently abstracted articles using previously published criteria to determine the presence of analytic errors.

RESULTS

One hundred fourteen susceptible articles were found published in 15 journals, 4 journals published the majority (71 of 114 or 62.3%) of studies, 40 were intervention studies, and 74 were noninterventional studies. The unit of analysis error was present in 19 (48%) of the intervention studies and 31 (42%) of the noninterventional studies (overall error rate 44%). The frequency of the error decreased between 1994-1999 (N = 38; 65% error) and 2000-2005 (N = 76; 33% error) (P = 0.001).

CONCLUSIONS

Although the frequency of the error in published studies is decreasing, further improvement remains desirable.

Physician attitudes toward end-stage heart failure: a national survey

BACKGROUND

Despite recent improvements in medical therapies, heart failure remains a prevalent condition that places significant burdens on providers, patients, and families. However, there is a paucity of data published describing physician beliefs about heart failure management, especially in its advanced stages.

METHODS

In order to better understand physician decision-making in end-stage heart failure, we used a stratified random sampling of physicians obtained from the Master File of the American Medical Association to survey cardiologists (n=600), geriatricians (n=250), and internists/family practitioners (n=600).

RESULTS

Response rate was 59.6% (highest among geriatricians). The vast majority (>90%) of respondents cited similarities between the clinical trajectory of end-stage heart failure and lung cancer or chronic obstructive pulmonary disease; however, only 15.7% stated that they could predict death at 6 months "most of the time" or "always." Inpatient volume was a predictor of confidence in predicting mortality (odds ratio=1.38, 95% confidence interval, 1.36-1.40). Less than one quarter of respondents formally measure quality of life. The experience with deactivation of implantable cardioverter defibrillators was limited: 59.8% of cardiologists, 88.0% of geriatricians, and 95.1% of internal medicine/family practice physicians have had 2 or fewer conversations with patients and families about this option.

CONCLUSIONS

Significant gaps in knowledge about and experience with end-stage heart failure exist among a large proportion of physicians. The growing prevalence and highly symptomatic nature of heart failure highlight the need to further evaluate and improve the way in which care is delivered to patients dying from the disease.

Economic burden of heart failure in the elderly

Heart failure (HF) ranks among the most costly chronic diseases in developed countries. At present these countries devote 1-2% of all healthcare expenditures towards HF. In the US, these costs are estimated at $US30.2 billion for 2007. The burden of HF is greatest among the elderly, with 80% of HF hospitalizations and 90% of HF-related deaths in this cohort. As a result, approximately three-quarters of the resources for HF care are consumed by elderly patients. As demographic shifts increase the number of elderly individuals in both developed and developing nations, the resources devoted to HF care will likely further increase. Hospitalization accounts for roughly two-thirds of HF costs, but procedures, outpatient visits and medications also consume significant financial resources. HF also adversely impacts patient quality of life, and these relevant effects may not be captured in pure cost analyses. The cost effectiveness of several pharmacological interventions has been explored. In general, neurohormonal antagonists used for outpatient treatment of chronic HF are relatively cost effective, in part by reducing hospitalizations. Because HF poses such an enormous financial burden, efficient resource allocation for its management is a major societal and governmental challenge. In order to make informed decisions and allocate resources for HF care rationally, detailed data regarding costs and resource use will be essential. Further studies are needed to examine the impact of pharmacological and non-pharmacological interventions on costs and resource use in elderly individuals with HF.

Trends in market demand for internal medicine 1999 to 2004: an analysis of physician job advertisements

BACKGROUND

The health care marketplace has changed substantially since the last assessment of demand for internal medicine physicians in 1996.

METHODS

We reviewed internal medicine employment advertisements published in 4 major medical journals between 1996 and 2004. The number of positions, specialty, and other practice characteristics (e.g., location) were collected from each advertisement.

RESULTS

Four thousand two hundred twenty-four advertisements posted 4,992 positions. Of these positions, jobs in the Northeast (31% of positions) or single specialty groups (36.8% of positions) were most common. The relative proportion of advertisements for nephrologists declined (P < .001), while the relative proportions of advertisements for critical care specialists (0.5% in 1996 to 1.7% in 2004, P = .004) and hospitalists (1.0% in 1996 to 12.1% in 2004, P < .001) increased. Advertisements for outpatient-based generalist positions (i.e., Primary Care and Internal Medicine) declined (-2.7% relative annual change, 95% confidence interval [95% CI] -4.1%, -1.2%) between 1996 and 2004, a decrease largely due to a substantial decline in advertisements noted between 1996 and 1998. However, over the entire time period, the combined proportion of advertisements for all generalists (hospitalists and outpatient-based generalists) did not change (0.5% relative annual change, 95% CI -0.8% to 2.0%).

CONCLUSIONS

Since 1996, demand for the majority of medical subspecialties has remained constant while relative demand has decreased for primary care and increased for hospitalists and critical care. Increase in demand for generalist-trained hospitalists appears to have offset falling demand for outpatient generalists.

Heart failure disease management: implementation and outcomes

Millions of dollars are being spent to identify new therapies to improve mortality and morbidity for the growing epidemic of patients sustaining heart failure. However, in clinical practice, these therapies are currently underused. To bridge the gap between proven therapies and clinical practice, the medical community has turned to disease management. Heart failure disease management interventions vary from vital-sign monitoring to multidisciplinary approaches involving a pharmacist, nutritionist, nurse practitioner, and physician. This review attempts to categorize these inventions based on location. We compared the published results from randomized, controlled trials of the following types of heart failure disease management interventions: inpatient, clinic visits, home visits, and telephone follow up. Although research shows an improvement in the quality of care and a decrease in hospitalizations for patients sustaining heart failure, the economic impact of disease management is still unclear. The current reimbursement structure is a disincentive to providers wanting to offer disease management services to patients sustaining heart failure. Additionally, the cost of providing disease management services such as additional clinical visits, patient education materials, or additional personnel time has not been well documented. Most heart failure disease management studies do confirm the concept that providing increased access to healthcare providers for an at-risk group of patients sustaining heart failure does improve outcomes. However, a large-scale randomized, controlled clinical trial based in the United States is needed to prove that this concept can be implemented beyond a single center and to determine how much it will cost patients, providers, healthcare systems, and payers.

Economic burden of heart failure: a summary of recent literature

OBJECTIVE

We reviewed literature published from 1995 to 2002 to highlight findings on the economic burden of heart failure (HF). Methods A key-word search of literature indexes for relevant citations identified 54 articles that were then summarized for findings on HF economics.

RESULTS

Results were described in terms of burden of illness, cost-effectiveness analysis, and resource utilization and costs. Hospitalization of the elderly is the driving force behind HF costs. Interventions that decrease the frequency of hospital admissions while maintaining clinical and patient reported outcomes are considered a high priority among decision makers and clinicians. Although the cost-effectiveness of therapy with beta-adrenergic blocking agents has been well established in the literature, the cost-effectiveness of hospital- or home-based HF management programs is still under debate. The issues of payer status and physician specialty impact on decreased hospital admission and cost have been inconclusive.

CONCLUSIONS

Any intervention capable of decreasing even a small fraction of adverse outcomes, most notably hospital admission and length of stay, could trigger significant cost savings in the management of HF. Public policy makers, together with clinicians identifying cost saving or cost-effective interventions in their practice, are expected to increase their efforts to evaluate the cost-effectiveness and outcomes of medical and pharmacologic interventions in HF.

A review of the application of propensity score methods yielded increasing use, advantages in specific settings, but not substantially different estimates compared with conventional multivariable methods

OBJECTIVE

Propensity score (PS) analyses attempt to control for confounding in nonexperimental studies by adjusting for the likelihood that a given patient is exposed. Such analyses have been proposed to address confounding by indication, but there is little empirical evidence that they achieve better control than conventional multivariate outcome modeling.

STUDY DESIGN AND METHODS

Using PubMed and Science Citation Index, we assessed the use of propensity scores over time and critically evaluated studies published through 2003.

RESULTS

Use of propensity scores increased from a total of 8 reports before 1998 to 71 in 2003. Most of the 177 published studies abstracted assessed medications (N=60) or surgical interventions (N=51), mainly in cardiology and cardiac surgery (N=90). Whether PS methods or conventional outcome models were used to control for confounding had little effect on results in those studies in which such comparison was possible. Only 9 of 69 studies (13%) had an effect estimate that differed by more than 20% from that obtained with a conventional outcome model in all PS analyses presented.

CONCLUSIONS

Publication of results based on propensity score methods has increased dramatically, but there is little evidence that these methods yield substantially different estimates compared with conventional multivariable methods.