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Yet some insurance plans continue to use generalists to direct treatment
It runs counter to the currents of managed care: CHF patients fare better when cardiologists get involved in their care, compared to going it alone with their primary care physicians (PCP). Investigators from Henry Ford Hospital in Detroit and the Mary Imogene Bassett Research Institute in Cooperstown, NY, followed hospitalized CHF patients who had been placed in one of three subgroups:
- patients treated by someone other than a cardiologist;
- patients whose attending physician was a cardiologist;
- patients who had consultation from a cardiologist but whose attending physician was not a cardiologist.1
The investigators’ conclusions: Hospitalized patients treated by cardiologists are less likely to be readmitted and more likely to have better quality of life than those treated by physicians outside the specialty. Yet, wrote the authors, some managed care plans are placing increasing emphasis on the role of the PCP in the treatment of CHF. (See related article, p. 111.)
For their study, the investigators followed nearly 2,500 patients in 10 community hospitals for six months and looked at severity of illness, process of care, and clinical outcomes. After measuring length of stay (LOS), mortality, readmission, and quality of life, they found:
- Patients who received direct care by cardiologists have a lower mortality rate, shorter LOS, and better quality of life scores than those treated by noncardiologists.
- Cardiologist-treated patients were more likely to receive the recommended diagnostic tests and treatment strategies.
- Treatment by cardiologists was associated with higher hospital charges and slightly lower risk of readmission for CHF.
- Compared to treatment by noncardiologists with no cardiologist consult, consultative care by cardiologists was associated with longer LOS, higher charges, better quality of life after discharge, and lower risk of readmission for CHF.
- Compared to treatment by noncardiologists, neither direct nor consultative care by cardiology specialists was associated with a lower adjusted mortality risk.
- Patients treated or consulted by a cardiologist were more likely to have the cause of their CHF documented in their charts, to have angiotensin-converting enzyme (ACE) inhibitors prescribed, to undergo echocardiograms or radionuclide ventriculograms, and to receive dietary counseling and case management strategies.
The authors report the reason for cardiologists’ greater success was having the expertise to perform many of the new treatment modalities for CHF. Lead author, Edward F. Philbin, MD, a cardiologist in the Section of Heart Failure and Cardiac Transplantation at Henry Ford Hospital, wrote, "Inasmuch as half of all CHF patients receive their care in nonteaching hospitals, the implications of this study are not trivial. It is not known whether more rigorous compliance with published guidelines by noncardiologists would offer the same benefits as cardiology specialty care. In our opinion, the relationship between physician specialty, process of care, and clinical outcomes requires further study before effective sweeping health manpower recommendations can be made."
Philbin says his study grew out of a project in which 10 community hospitals in upstate New York worked together on a collaborative quality improvement program. In the course of that program, he and his colleagues gathered detailed information on 2,900 patients, then went back and asked the chart abstractors whether particular patients were managed exclusively by a noncardiologist, by a cardiologist, or by a noncardiologist with a cardiologist consult. Philbin says the length of time that all patients had heart failure, preceding hospital care, was similar among the three groups, averaging three years.
He was unable to say when consultations were done in the patients’ treatment because in every day treatment of these patients, there is a wide range of how consults are used. "We know it’s not that simple in real life," says Philbin. "Sometimes a consult totally takes over, and a primary totally surrenders. At other times, the consult does a quick, simple test and maintains a minimal presence and has minimal influence on day-to-day decision making." Philbin says he and his colleagues didn’t look at those variables, but in the group of patients managed by noncardiologists, there was no involvement by cardiologists, and in the group managed by cardiologists, there was no involvement by PCPs. "In the third group who had cardiologist consults, there was variability."
He says the differences between internists or other PCPs and cardiologists are subtle: "The question of quality of care among specialties is still controversial and unanswered. Just how one measures quality is an elusive thing, and to develop a single score for a physician’s treatment of a given disease is not agreed upon because the use of a medication may be appropriate in one patient and not another."
Philbin says he’s leery of going out on a limb and saying that his study proves demonstrably better care by cardiologists. He says that if you look at studies of self-reported behavior — questionnaires on ACE inhibitor use, for example — cardiologists tend to get higher scores than PCPs. They are more likely to choose the right answers on tests.
"That may be a reflection of their practice or just a reflection of their better cognitive knowledge of the area," he says. "But when you physically measure the practices of cardiologists and of internists or other primary care doctors and what they’re doing, the differences between groups is not as profound."
But Philbin says there are some differences favoring the cardiologists. "And even among cardiologists, there are differences. Heart failure cardiologists do better than general cardiologists in the area of heart failure."
CHF Disease Management asked several experts in the field for their comments on the study:
- Gordon Ewy, MD, chief of cardiology at the University of Arizona Health Sciences Center in Tucson agrees with the study’s lead author. "You can’t generalize and say that any cardiologist is better than any primary care doctor. Cardiologists differ. There are some whose major interest is catheterization and angioplasty, and they have very little interest in CHF. Those cardiologists may not do any better treating CHF than a primary care physician who is very interested in heart failure and keeps up on the literature. The ideal situation is to have a cardiologist interested in keeping up with the rapidly changing field of CHF management as either a consult or the primary doctor." Ewy says that CHF mortality is worse than most cancers. "If I had a cancer," he says, "I wouldn’t have a primary care physician deciding how to treat it. In the same way, if I had CHF, I’d want a specialist treating that."
- Bobby Miller, supervisor of the Optum Disease Management Program in Dayton, OH, adds treatment success often depends on the knowledge base of the PCP and the level to which he or she keeps up to date on CHF.
- Douglas Chapman, MD, director of The Heart Failure Center at Alegent Medical Center in Omaha, NE, says that he strongly agrees with the investigators’ findings: "It’s like asking, How does the cardiologist and the general surgeon’s approach to appendectomy differ?’ One is trained to take care of the condition, and one is not. One keeps current on the disease process, and one does not." Chapman says that a physician’s approach to taking care of the patient is deeply rooted in training and the everyday experience of keeping up with the literature on the disease process, and PCPs don’t concentrate on the one condition.
- Elgin K. Kennedy, MD, a PCP practicing in Hillsborough, CA, says it should be up to the patient. "[PCP] patients should always have the final choice whether their CHF should be managed by a PCP who may know them personally very well, or a specialist cardiologist who may know their disease very well. The American public will continue to demand the right to make their own choices."
- Kenneth McDonagh, MD, medical director of the disease management program at AstraZeneca Pharmaceutical Company in Wilmington, DE, says that more studies need to be done before this controversy can be resolved. "The authors [of the study] feel they’ve found something, but they don’t seem to be sure how much of a difference there is [between care by a cardiologist and care by a noncardiologist] and what it means." McDonagh says that PCPs do require additional resources to provide care to their heart failure patients to put that care on par with that rendered by cardiologists, and that needs to be explored before it can be determined that CHF patients should receive all their care from cardiologists.
"My take is that the investigators’ research was well-designed," he says. "They uncovered some practice differences. They found what appear to be some differences in the care of patients, including the performance of tests, counseling, and case management."
"To treat CHF patients effectively, primary care doctors have to be up on the new treatments. It’s been common knowledge for the last five years that ACE inhibitors are one of the basic components of CHF treatments. The drugs have been documented as part of the [Agency of Healthcare Policy Research] guidelines for those patients since 1994, and more recently, a revised guideline was published jointly by the American Heart Association and the American College of Cardiology." McDonagh says that managed care plans have undertaken initiatives to educate PCPs on the fact that ACE inhibitors are part of the guidelines.
- Evadell Tangquist, RN, patient education coordinator for Northwest Medical Center in Thief River Falls, MN, also agrees. She says there are no cardiologists at that facility, but they have access to several in nearby Fargo, ND, so some of their patients see or consult with cardiologists. "Yes," she says, "CHF patients do better with at least a consult with a cardiologist. In my experience, I don’t see the newer ACE inhibitors or beta blockers on a chart unless a patient has at least a cardiologist consult."
- Santosh G. Menon, MD, a cardiologist in the division of cardiology at the University of Kentucky in Lexington says care by a cardiologist is most helpful for the advanced CHF patient, "especially for the patient who keeps coming back to the hospital." It’s advantageous to have a cardiologist seeing them and getting them on the drugs they need. What is the main difference between care by a PCP and a cardiologist? The cardiologist’s treatment is more aggressive. Menon says that often PCPs underutilize ACE inhibitors, beta-blockers, and other drugs known to be beneficial to the patient. "Those drugs have been shown clinically to improve morbidity and mortality," he says, "and maximizing their use is done better by the cardiologists."
Ewy says the problem with heart failure is, once a patient has it, the condition begets more heart failure. "If you just treat the hemodynamics, it’s as if you are painting the walls without getting rid of the termites. You need to treat all the neurohumoral imbalances and the new ones that come along. The literature is clear on the standard of care — so clear that there are now heart failure clinics run by nurse practitioners who simply follow guidelines. And they do well."
But he says that extant CHF guidelines are for the management of CHF due to systolic dysfunction. "The study talked about patients with ejection fractions of less than 40%, so the guidelines would apply to them." But a high percentage of patients, he says, particularly the elderly, have CHF due to diastolic dysfunction not systolic, and no guidelines exist for that. Philbin’s study does not apply to all patients. The guidelines the study was based upon will be changed in the near future because of new studies on beta-blockers and spironalactone, a diuretic agent that blocks the renal tubular actions of aldosterone. (See CM, September 1999, p. 102.)
1. Philbin EF, Weil HFC, Erb TA, et al. Cardiology or primary care for heart failure in the community setting: Process of care and clinical outcomes. Chest 1999; 116(2):346-354.