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 ratio adjusted 3.01; 95% confidence interval 1.84 to 4.89, p <0.001; and nonhospitalists vs cardiologists, hazard ratio adjusted 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.
Hospitalists solely care for admitted patients, and previous studies have suggested that acute decompensated heart failure (ADHF) patients managed by hospitalists have reduced hospital length of stay, care that is more closely adherent to quality of care and treatment guidelines and better postdischarge follow-up of patients compared with care delivered by nonhospitalists. Although previous studies suggest that ADHF patients managed by cardiologists tend to have better outcome measures compared with patients managed by generalists, differences in practice patterns between hospitalists, nonhospitalists, and cardiologists have not been well described in the literature. The aim of this study was to evaluate the demographics, clinical characteristics, and clinical outcomes of consecutive patients discharged from a large urban-based community hospital with the principal diagnosis of ADHF by 3 provider types—cardiologists, hospitalists, and nonhospitalists. In addition, adherence to the Joint Commission HF core measures as a function of provider type in the setting of ADHF hospitalization was analyzed.
Methods
The study included analysis of consecutive patients discharged from a large urban-based community hospital, Catholic Medical Center, Manchester, New Hampshire, with primary discharge diagnosis of ADHF from January 2006 to December 2007. As we elected to analyze the provider type adherence to the Joint Commission HF core measures, the eligibility for the study included age ≥18 years and patients not discharged to an acute care hospital or transferred to acute rehabilitation facility or hospice. Patients who left against medical advice or died in the hospital (n = 36) were excluded from the study. Thus, a total of 496 patients were included in the study.
The study population was divided into 3 groups based on the discharging provider: cardiologists’ patients (n = 148), hospitalists’ patients (n = 182), and nonhospitalists’ patients (n = 166). The hospitalists’ and nonhospitalists’ patients were managed solely by them, whereas cardiologists’ patients were cared for by a team of full-time cardiologists. Data collection was done by the investigators from the medical and electronic records of the patient’s initial presentation, progress notes, and the discharge day instructions including the discharge summary. Stage 3 or 4 kidney disease was diagnosed according to glomerular filtration rate in ml/min/1.73 m 2 calculated by modification of diet in renal disease formula. Stage 3 and 4 kidney disease was considered when glomerular filtration rate was 30 to 59 ml/min/1.73 m 2 and 15 to 29 ml/min/1.73 m 2 , respectively.
Catholic Medical Center is an approved Joint Commission performance system vendor for the Joint Commission HF failure core measure sets. Adherence to the core measures was analyzed based on the analysis of the health care provider’s medical records for adherence to HF core measure sets. These include assessment and documentation of left ventricular ejection fraction (LVEF) as a measure of left ventricular function before or during hospitalization or is planned for assessment after discharge ; prescription of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) for patients with left ventricular systolic dysfunction (LVEF ≤40%) ; provision of written discharge instruction or educational material regarding activity, weight, diet and fluid restriction, daily weight monitoring, discharge medications, and follow-up appointment; and counseling on smoking cessation for cigarette smokers or who have smoked cigarettes within past 1 year of discharge from the hospital. To analyze the adherence of the provider type to the Joint Commission HF core measures, only the eligible patients for each item of the core measures were compared.
Patients were followed for cardiac-related death or ADHF readmission from the day discharged from the hospital for up to a period of 6 months. The length of hospital stay and direct hospital cost for each hospital admission was provided by the hospital finance department. Cardiac-related death was identified as heart failure, cardiac arrest, or myocardial infarction. Mortality data were obtained from the death certificate issued by the primary care physician at the time of death and social security death index. The institutional review board at the Catholic Medical Center approved the study.
Among the different provider types, the demographics, clinical characteristics, laboratory tests, and hemodynamics of the study population with analysis of variance and Kruskal-Wallis tests for continuous variables as appropriate and chi-square test for categorical variables were compared. Associations between provider groups for compliance with the Joint Commission HF core measures were assessed using the chi-square test.
Kaplan-Meier survival analysis was used to measure the 6-month cardiac-related mortality between the 3 provider types. Cox proportional hazards analysis was used for univariate and multivariate modeling of the ADHF-related readmission event rate and the composite of death and/or readmission event rate between the provider type pair: cardiologists versus hospitalists and cardiologists versus nonhospitalists. Variables included in the multivariate model include those found to be significant by univariate analysis; variables examined included age, gender, history of diabetes mellitus, history of HF, coronary artery disease and LVEF ≤40%, LVEF >50%, New York Heart Association functional class III and IV, hypertension, clinical signs and symptoms, blood urea nitrogen, serum creatinine, hemoglobin, and use of β blockers, ACEI, and/or ARB. Hazard ratios (HRs) and 95% confidence intervals (CIs) were reported. Multiple linear regression analysis was used to calculate the adjusted outcomes for the hospital length of stay and direct hospital costs between the provider types. Data analyses were performed using SPSS (PASW), version 17 for windows (SPSS, Inc., Chicago, Illinois); for all comparisons, p values ≤0.05 were considered statistically significant.
Results
The baseline clinical characteristics of the patients belonging to the 3 different provider types are listed in Table 1 . Patients cared for by cardiologists tended to be younger, compared with those cared for by hospitalists and nonhospitalists (70.4 vs 76.8 vs 77.3 years, p <0.001), and were more likely to have more severe left ventricular dysfunction (mean LVEF 22.6% vs 25.5% vs 27.8%, p = 0.003) and had New York Heart Association class III and IV symptoms (79.9% vs 59.5% vs 63.3%, p <0.001), with a correspondingly higher prevalence of symptoms of orthopnea and paroxysmal nocturnal dyspnea.
| Variable | Cardiologists (N=148) | Hospitalists (N= 182) | Non-Hospitalists (N = 166) | P value |
|---|---|---|---|---|
| Age (years) | 70.4 ± 13.3 | 76.8 ± 13.5 | 77.4 ± 11.9 | .001 |
| Men | 60% | 50% | 48% | .07 |
| White | 98% | 98% | 99% | .30 |
| Coronary artery disease | 71% | 60% | 63% | .12 |
| Hypertension | 89% | 88% | 87% | .77 |
| Heart failure | 34% | 26% | 37% | .10 |
| Atrial fibrillation | 47% | 43% | 46% | .70 |
| Coronary artery bypass surgery | 37% | 28% | 27% | .14 |
| Diabetes mellitus | 32% | 40% | 46% | .03 |
| Dyslipidemia | 80% | 69% | 66% | .01 |
| Chronic obstructive pulmonary disease | 28% | 33% | 30% | .63 |
| Smoking | 74% | 77% | 63% | .01 |
| LVEF ≤ 40% | 68% | 49% | 46% | .03 |
| LVEF ≥ 50% | 27% | 41% | 45% | .003 |
| LVEF ≤ 40% (mean ± SD) | 22.6 ± 8.5 | 25.5 ± 10.3 | 27.8 ± 10.2 | .003 |
| LVEF ≥ 50% (mean ± SD) | 61.4 ± 5.0 | 61.6 ± 5.7 | 62.6 ± 5.5 | .36 |
| Clinical / lab characteristics | ||||
| Heart rate (beats/min) | 83 ± 20 | 92 ± 23 | 86 ± 23 | .001 |
| Systolic Blood pressure (mm Hg) | 126 ± 21 | 131 ± 35 | 134 ± 28 | .07 |
| S3 gallop | 60% | 47% | 55% | .06 |
| Rales | 90% | 85% | 92% | .07 |
| Orthopnea | 70% | 62% | 52% | .004 |
| Paroxysmal Nocturnal Dyspnea | 87% | 76% | 79% | .01 |
| Jugular venous distension | 65% | 69% | 70% | .58 |
| Stage III – V kidney disease | 43% | 45% | 47% | .81 |
| NYHA III and IV | 80% | 60% | 63% | .0001 |
| Hemoglobin level (g/dL) (mean± SD) | 12.9 ± 2.1 | 12.3 ± 2.4 | 12.1 ± 2.0 | .006 |
| Serum sodium (mmol / L) (mean± SD) | 138 ± 4 | 138 ± 4 | 138 ± 4 | .66 |
| Blood urea nitrogen (mg/dL) | 25 (14-54) | 32 (15-74) | 26 (14 – 59) | .02 |
| Serum creatinine (mg/dL) | 1.3 (0.8-2.2) | 1.4 (0.9 – 3.1) | 1.3 (0.8 – 2.5) | .13 |
| Glomerular Filtration Rate(ml/min/1.73 m 2 ) | 52.0 (25.0 – 76.7) | 42.5 (21.0 – 77.0) | 45.0 (22.1 – 76.9) | .001 |
| Serum BNP | 791 (221 -2411) | 820 (235 – 2500) | 719 (271 – 2000) | .56 |
| Intensive care unit hospital stay (days) | 12.1 | 5.3 | 4.1 | .0001 |
| Medical Insurance | ||||
| Medicare | 56% | 71% | 73% | .003 |
| Medicaid | 9% | 18% | 16% | .04 |
| Private | 33% | 2% | 4% | .0001 |
| Self pay and/or uninsured | 2% | 9% | 7% | .03 |
Adherences to different Joint Commission HF core measures among 3 different provider groups are listed in Table 2 . Cardiologists had the highest adherence to the Joint Commission HF core measures for the LVEF assessment (93% vs 78% vs 76%, p <0.001), smoking cessation counseling (100% vs 94% vs 92%, p = 0.02), and providing discharge instructions (100% vs 96% vs 90%, p = 0.001). Although cardiologists had numerically higher adherence with either prescribing ACEI and/or ARB (or documenting contraindication to prescription, such as impaired renal function) compared with hospitalists and nonhospitalists (96% vs 92% vs 91%, p = 0.67), the difference was not significantly different. A trend toward higher actual prescription of ACEI and/or ARB for patients discharged by cardiologists compared with hospitalists was found (77% vs 65%, p = 0.06); however, no difference between cardiologists and nonhospitalists was found.
| Joint Commission HF core measures | Provider adherence | P value | ||
|---|---|---|---|---|
| Cardiologists | Hospitalists | Non-Hospitalists | ||
| LVEF assessment ∗ | 93% | 78% | 76% | <0.001 |
| ACEI and / or ARB therapy † | 96% | 92% | 91% | 0.67 |
| Discharge instructions ‡ | 100% | 96% | 90% | 0.001 |
| Smoking cessation § | 100% | 94% | 92% | 0.02 |
∗ Eligible patients for cardiologists (n= 148), hospitalists (n=182) and non-hospitalists (n=166).
† Eligible patients for cardiologists (n= 100), hospitalists (n=90) and non-hospitalists (n=76).
‡ Eligible patients for cardiologists (n= 148), hospitalists (n=182) and non-hospitalists (n=166).
§ Eligible patients for cardiologists (n=110), hospitalists (n=140) and non-hospitalists (n=105).
Besides ACEI or ARB, at the time of discharge, a higher number of patients cared by cardiologists and hospitalists were discharged with the prescription of β blockers (87% vs 89% vs 74%, p <0.001) and statins (68% vs 72% vs 58%, p = 0.01), compared with nonhospitalists. There were no differences in prescribing patterns for digoxin and loop diuretics in different provider types ( Table 3 ). With respect to outcomes, despite having higher risk profiles, those patients with ADHF cared for by cardiologists had similar (if not numerically lower) 6-month cardiac-related death rates ( Figure 1 ), compared with those cared for by hospitalists and nonhospitalists (6%, 10.9%, and 11.4%, respectively, p = 0.12).
| Variables | Cardiologists (N=148) | Hospitalists (N= 182) | Non-Hospitalists (N = 166) | P value |
|---|---|---|---|---|
| Digoxin | 22% | 31% | 26% | .21 |
| β blockers | 87% | 89% | 74% | .0001 |
| Oral loop diuretics | 89% | 85% | 87% | .93 |
| Statin | 68% | 72% | 58% | .01 |
| Coumadin | 45% | 40% | 35% | .17 |
| ACEI /ARB | 77% | 65% | 72% | .06 |
| IV diuretics / drip | 22% | 3% | 2% | .0001 |
When examining rates for recurrent ADHF over the 6 months of follow-up ( Figure 2 ), patients treated by cardiologists were considerably less likely to be readmitted than those treated by hospitalists and nonhospitalists (16.2% vs 40.1% vs 34.9%, p <0.001). The composite outcome of death and/or readmission for ADHF at 6 months ( Figure 3 ) was, thus, significantly lower in patients attended by cardiologists than hospitalists and nonhospitalists (20.2% vs 43.4% vs 40.3%, p <0.001).
