Specialist or generalist care? A study of the impact of a selective admitting policy for patients with cardiac failure

CONTEXT

The debate on the respective roles of medical specialists and generalists has tended to portray them as alternatives, rather than seeking ways to build on the complementary skills of these professional groups.

OBJECTIVE

We wished to evaluate the impact of a selective admitting policy that attempts to exploit the complementary strengths of specialists and generalists.

DESIGN

Prospective cohort study of patients admitted to hospital with congestive heart failure.

SETTING

Public hospital in New South Wales, Australia.

PATIENTS

Subjects aged 60 years or more with congestive heart failure defined by the Framingham criteria (see Appendix).

INTERVENTION

A selective admission policy which referred patients with identifiable single system disorders to the relevant subspecialist, while patients with multiple medical problems were admitted under a general physician.

MAIN OUTCOME MEASURES

Length of hospital stay, survival, quality of life and satisfaction with care.

RESULTS

Two-hundred and seventy-five patients with congestive heart failure were followed up from admission to 1 year after discharge from hospital. Of these, 102 were cared for by cardiologists and 154 by generalists. The patients under the generalists were older, had greater co-morbidity, but appeared to have less severe cardiac disease than those cared for by cardiologists. The use of cardiac drugs and investigations was similar in the two groups. The generalists' patients had a longer length of hospital stay, but the cardiologists' patients had a higher mortality during the early follow-up period. There were no differences in levels of satisfaction with care or in health-related quality of life between the two groups of patients. Multivariate analysis suggested that any differences in outcomes between the two groups of patients were due to the severity of underlying disease, and co-morbidity, rather than the quality of care that was provided by the physicians.

CONCLUSIONS

It is possible to implement a hospital admission policy that selectively refers patients with congestive heart failure to specialists or generalists, according to the presence of co-morbid conditions, without adversely affecting the outcomes of care. Such a policy should represent optimum use of the complementary skills of these professional groups.

Elderly patients with heart failure: a study of satisfaction with care and quality of life

OBJECTIVE

To assess the level of patient satisfaction with care, patient quality of life, the relationship between these measures and hospital readmission rates, and patient outcomes.

METHODOLOGY

A prospective cohort study was conducted of all patients aged 60 years and over admitted to the John Hunter and Mater Hospitals, in the Hunter Area, in whom congestive heart failure contributed to the need for hospital admission. Patients recruited into the main study were then asked to complete a questionnaire on discharge from hospital. Patients were asked to complete the satisfaction questionnaire on discharge because this would reflect the patients' satisfaction with the overall stay. To provide a baseline quality-of-life score, patients were asked to complete a questionnaire 2 weeks after discharge.

FINDINGS

Overall scores on the satisfaction questionnaire were high, indicating that the patients were very satisfied with their care. There were six questions in which 17-35% of patients indicated some degree of dissatisfaction, four related to patient knowledge. No difference in satisfaction was found between patients who had or did not have a readmission. Quality-of-life results showed that patients who had a readmission had a significantly lower quality-of-life score at 12 month follow up (P=0.007) than those without a readmission.

CONCLUSION

This finding has supported our hypothesis that a higher level of quality of life would be related to fewer readmissions.