Impact of specialist follow-up in outpatients with congestive heart failure

Abstract

ResearchRecherche C ongestive heart failure (CHF) afflicts up to 2% of North American adults and, despite many advances in diagnosis and therapy, still portends a poor prognosis, with 1-year mortality of 30%-50%. [1][2][3][4][5] Although the prognosis of patients with CHF is poor even with optimal management, suboptimal diagnosis, investigation and treatment of heart failure and comorbidities (e.g., coronary artery disease) in community-dwelling patients contributes to poor survival. [6][7][8][9] In previous studies hospital inpatients with CHF who were cared for by specialists received more evidence-based therapies and had better outcomes than those cared for by nonspecialists.8,10-13 However, none of these studies examined the care delivered after discharge from hospital. Although management in specialized multidisciplinary clinics is associated with better outcomes, 14 it is unclear whether similar benefits can be expected when patients are cared for by specialist physicians operating outside the setting of a multidisciplinary clinic. Two recent studies from the United States that reported better outcomes with specialist care 7,15 were flawed, in that neither study adjusted for frequency of outpatient visits or the possibility of time-dependent bias 16 (whereby some variables, including the number of visits, will change over time).To address this important public health issue, we sought to determine whether there is a relation between ambulatory care follow-up and outcomes in patients with new-onset CHF. MethodsWe linked 4 databases maintained by Alberta Health and Wellness, which record individual patient interactions with the health care system in Alberta: the Discharge Abstract Database, which records information (including dates, diagnoses and procedures) on all admissions to any of 128 acute care facilities; the Ambulatory There is uncertainty about whether physician specialty influences the outcomes of outpatients with congestive heart failure after adjustment for differences in case mix. Our objective was to determine the impact of physician specialty on outcomes in outpatients with new-onset congestive heart failure. Methods: The study was a population-based retrospective cohort study involving patients with new-onset congestive heart failure discharged from 128 acute care hospitals in Alberta between Apr. 1, 1998, and July 1, 2000. Outcomes were resource utilization (clinic visits, emergency department visits and hospital admissions) and survival at 30 days and 1 year. Results: A total of 3136 patients were discharged from hospital with a new diagnosis of congestive heart failure (median age 76 years, 50% men). Of these, 1062 (34%) received no follow-up visits for cardiovascular care, 738 (24%) were seen by a family physician (FP) alone, 29 (1%) by a specialist (cardiologist or general internist) alone and 1307 (42%) by both a specialist and an FP. Compared with patients who received no follow-up cardiovascular care, patients who received regular cardiovascular follow-up visits with a physician had f...

Time-dependent analysis in CHF follow-up

“…3 Trial registry with electronic publication of research protocols before inception of each trial 4,5 and Web posting of complete data sets upon publication of the findings are 2 measures that could promote greater comprehensiveness and honesty in the reporting of trials.…”

Impact of heart failure clinic visit frequency on hospital admission rates

“…There is significant variability within clinical trials that demonstrated the efficacy of HFCs as a management strategy for patients with HF, and within clinical practice (7)(8)(9)(10). HFCs have expanded in number (11), but remain a scarce resource; therefore, determining the optimal recall frequency may assist in resource allocation.…”

A Canadian context for the Acute Study of Clinical Effectiveness of Nesiritide and Decompensated Heart Failure (ASCEND-HF) trial

“…This entity is the unhappy, but logical final path for a diverse group of cardiovascular conditions dominated by ischemic heart disease and hypertension, but also populated by valvular and cardiomyopathic disorders. It constitutes a major cause of morbidity and mortality, which in its acute form is associated with an annualized mortality of at least 21% and a high rehospitalization rate (1,2). Accordingly, heart failure accounts for not only a large burden to the health care system, but also one that has major economic repercussions; it is now the single largest expense for Medicare in the United States (3).…”