Elsevier

American Heart Journal

Volume 145, Issue 6, June 2003, Pages 1086-1093
American Heart Journal

Clinical investigations: congestive heart failure
Association of consultation between generalists and cardiologists with quality and outcomes of heart failure care

A paper based on preliminary results of this study was presented by Dr Ahmed at the 7th World Congress on Heart Failure, Vancouver, Canada, in July 2000.
https://doi.org/10.1016/S0002-8703(02)94778-2Get rights and content

Abstract

Background

The appropriate roles for generalists and cardiologists in the care of patients with heart failure (HF) are unknown. The objective of this retrospective cohort study was to determine whether consultation between generalists and cardiologists was associated with better quality and outcomes of HF care.

Methods

We studied left ventricular function evaluation (LVFE) and angiotensin-converting enzyme inhibitor (ACEI) use and 90-day readmission and 90-day mortality rates in patients with HF who were hospitalized. Patient care was categorized into cardiologist (solo), generalist (solo), or consultative cares. The processes and outcomes of care were compared by care category using logistic regression analyses fit with generalized linear mixed models to adjust for hospital-related clustering.

Results

Of the 1075 patients studied, 13% received cardiologist care, 55% received generalist care, and 32% received consultative care. More patients who received consultative care (75%) received LVFE than patients who received generalist care (36%) and cardiologist care (53%; P < .001). Fewer patients who received solo care (54% each) received ACEI compared with 71% of patients who received consultative care (P < .001). After multivariable adjustment, consultative care was associated with higher odds of LVFE than generalist care (adjusted odds ratio [OR], 6.06; 95% CI, 3.97-9.26) or cardiologist care (adjusted OR, 2.96; 95% CI, 1.70-5.13) care. Consultation was also associated with higher odds of ACEI use compared with generalist (adjusted OR, 2.42; 95% CI, 1.42-4.12) or cardiologist (adjusted OR, 2.32; 95% CI, 1.14-4.72) care. Compared with patients who received generalist care, patients who received consultative care had lower odds of 90-day readmission (adjusted OR, 0.54; 95% CI, 0.34-0.86).

Conclusion

Collaboration between generalists and cardiologists, rather than solo care by either, was associated with better HF processes and outcomes of care.

Section snippets

Subjects

We studied Medicare beneficiaries, 65 years and older, discharged in 1994, with a principal discharge diagnosis of HF from 11 Alabama hospitals. This study is a secondary analysis of the baseline dataset of a HF quality improvement project conducted by the Alabama Quality Assurance Foundation (AQAF), the peer review organization for Alabama. The details of the study methodology and subject selection criteria have been described elsewhere.20 In brief, with Medicare claims data for index

Patient characteristics

Subjects (N = 1075) had a mean (± SD) age of 79 (± 7.5) years, 60% were women, and 18% were African American. Solo generalists cared for 588 patients (55%), solo cardiologists cared for 145 patients (13%), and 342 patients (32%) received consultative care. A total of 883 patients were eligible for an LVF evaluation, and 433 patients (49%) received an LVF evaluation during the index hospitalization. A total of 619 patients were eligible for ACE inhibitor therapy, and 363 patients (59%) were

Mortality and readmission

The overall 90-day mortality rate was 22%, and the 90-day readmission rate among patients who were discharged alive (n = 988) was 15%. The care category was not associated with mortality (Table V). However, compared with patients cared for by generalists, patients cared for by consultation had lower odds of having a HF-related readmission within 90 days of discharge (adjusted OR, 0.54; 95% CI, 0.34-0.86).

Discussion

The results of our study demonstrate that collaboration between generalists and cardiologists was associated with improved processes and outcomes of care for patients with HF who were hospitalized. These findings are important because more than half of all patients with HF in the United States receive solo care from generalists, and 10% to 30% of all patients with HF in the United States receive solo care from cardiologists,11, 28, 29 proportions that are consistent with those we observed.

Center for Medicare and Medicaid Services disclaimer

The analyses on which this publication is based were performed under Contract Number 500-96-P60, titled “Utilization and Quality Control Peer Review Organization for the State of Alabama,” sponsored by the Center for Medicare and Medicaid Services (CMS, formerly HCFA), Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Service, nor does mention of trade names, commercial products, or

Acknowledgements

We thank Crystal Walls for her secretarial assistance and Robert Farmer of Alabama Quality Assurance Foundation and Eric Bodner of University of Alabama at Birmingham Center for Aging for their contribution in data management.

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