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Outcomes differ for HF patients cared for by cardiologists, generalists
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Processes of care and clinical outcomes differ for patients newly hospitalized with HF attended to by different physician specialists, researchers found.
According to results of a study evaluating outcomes for HF patients who received in-hospital care from a cardiologist, generalist (e.g., internist or family doctor) or generalist with cardiology consultation, risk for mortality at 30 days (OR=1.50; 95% CI, 1.18-1.91) and 1 year (OR=1.29; 95% CI, 1.10-1.50) was higher for patients treated by generalists compared with cardiologist care. Additionally higher was the 1-year composite outcome of death and hospital readmission with generalist care alone. Patients who received care from a generalist with cardiology consultation did not have an increased risk for adverse outcomes when compared with patients who received cardiology care only.
“These data reveal a general trend with both 30-day and 1-year mortality increasing in succession from patients treated by cardiologists, to generalists with a cardiology consult, to generalists alone, across almost every stratum examined,” researchers wrote in American Heart Journal.
The study included 7,634 patients newly hospitalized for HF in Ontario, Canada. More than 64% were cared for by generalists without a cardiology consult, 20% by cardiologists and 16% by generalists with a cardiology consult. Distribution of care varied widely across hospitals. Patients who received cardiologist care tended to be younger, male, present with more associated cardiac conditions but fewer noncardiac comorbidities, and were less likely to have a do not resuscitate (DNR) order compared with patients who received generalist care.
Jack V. Tu, PhD, told Cardiology Today that although the overall care provided by both types of physicians is good, there are significant opportunities to improve quality of care.
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“For example, we found that beta-blockers were underused in HF patients, particularly when the attending physician was a generalist. We also found greater use of several other evidence-based diagnostic tests and treatments when the attending physician was a cardiologist as compared to a generalist,” said Tu, senior scientist and head of the Cardiovascular and Diagnostic Imaging Program at the Institute for Clinical Evaluative Sciences, Ontario.
The physician specialty-related differences in outcomes reflect a combination of both case-mix differences and differences in the use of certain processes of care, the researchers said. Less frequent use of echocardiography and other diagnostic procedures by generalists may indicate a lack of access to resources in certain settings and cardiologists may adhere more closely to evidence-based guidelines, resulting in more frequent use of therapies, they noted. In addition, the data suggest that a significant proportion of the differences in this study may reflect the increasing use of do not resuscitate (DNR) orders in patients with HF who are treated by generalist physicians.
“We recognize that generalists have a very difficult job because they need to treat patients with many different complex conditions. The challenge will be how we can help both generalists and cardiologists improve their management of HF, recognizing the challenges they both face with an increasingly sicker patient population with multiple chronic conditions in addition to HF,” Tu said.
The researchers acknowledged that HF is “such a common problem” that it is not possible to have cardiologist care for all patients.
“Our findings suggest that a greater focus on encouraging generalist physicians to use certain therapies, such as beta-blockers, may be an effective strategy in reducing specialty-related differences in patient outcomes,” the researchers concluded.
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Disclosure: Dr. Tu reports research support by a Canada Research Chair in Health Services Research and a Career Investigator award from the Heart and Stroke Foundation of Ontario.
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