Association of Consultation Between Generalists and Cardiologists With Quality and Outcomes of Heart Failure Care

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Objective. The objective of this retrospective cohort study was to determine if consultation between generalists and cardiologists was associated with better quality and outcomes of heart failure (HF) care. Background. The appropriate roles for generalists and cardiologists in the care of patients with HF are unknown. Methods. We studied left ventricular function evaluation (LVFE) and angiotensin-converting enzyme (ACE) inhibitor 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 care groups. 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<0.001). Fewer patients who received solo care (54% each) received ACE inhibitor compared with 71% of patients who received consultative care (p<0.001). After multivariable adjustment, consultative care was associated with higher odds of LVFE than generalist care (adjusted odds ratio [OR], 6.06; 95% confidence interval [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 ACE inhibitor 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.—Ahmed A, Allman RM, Kiefe CI, et al. Association of consultation between generalists and cardiologists with quality and outcomes of heart failure care. Am Heart J. 2003;145(6):1086–1093. Comment. Over the past decade we have become much more in tune with the need for evidence-based medicine using outcomes and various quality-of-care measurements. As managed care has made tremendous inroads into how we deliver health care, major disparities have been created based on individual preferences for management approach. Frequently a generalist will take care of patients who have “routine” congestive HF without perceiving a need for cardiovascular consultation. In the alternative, there are many times when a specialist will treat a patient with congestive HF without a generalist participating in the care of the patient. The authors of this paper looked at the roles for each of these health care providers and the care of patients with congestive HF. The goal was to determine if consultation between these two groups of physicians would enhance quality of care and outcomes. Measures used were angiotensin-converting enzyme inhibitor use, 90-day readmission, and 90-day mortality rates in HF patients who had been hospitalized. The type of patient care was categorized by whether it was a cardiologist, a generalist, or a combination of the two that managed the patient through the hospitalization. The type of care and the outcomes were then compared using a logistic regression analysis. The results of the trial looked at 1075 patients. Among this group, 13% received care primarily from a cardiologist, 55% received solo care from the generalist, and 32% received care via the consultative approach. The authors found that consultative care, wherein the management was based on input from both the generalist and the cardiologist, was associated with the best possible outcomes. Various parameters were looked at to come to this conclusion. Based on the data, it is the authors' belief that joint care by generalist and cardiologist rather than solo management by either should be the preferred method of treatment. Although each physician specialty type has its own unique approach, it is often through the combination of looking at the total picture while still being organ focused that will obtain the best results. Hopefully, this and other trials can support this idea and therefore enhance our ability to care for a very sick group of patients for whom there is no cure yet.