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Abstract title: Cardiology Specialty Care Improves Outcomes in Outpatients with New Onset Heart Failure

Author(s):
M Ansari - San Francisco VAMC, University of California, San Francisco
M Alexander - Division of Research, Kaiser Permanente Medical Care Program, Northern California Region, Oakland, CA
A Tutar - University of Louisville, Louisville, Kentucky
BM Massie - San Francisco VAMC, University of California, San Francisco

Objectives: Several studies have sought differences in outcomes and quality of care between CHF patients (Pts) managed by cardiologists (Card) and generalists (Genl), but most focused on the in-patient setting, where Pts often represent failures of medical management. Therefore, we examined the characteristics and outcomes of outpatients with new onset CHF who were managed in part by Card or almost exclusively by generalists.

Methods: After excluding Pts with a prior diagnosis or hospitalization for CHF and terminal comorbidities, records from a cohort of 403 Pts with a new outpatient CHF diagnosis in a large staff-model HMO from 7/96-8/97. Card care was defined as >3 visits or >25% of total medical outpatient visits to a Card (n=198). The prespecified outcome measure, death plus cardiovascular (CV) hospitalization, was assessed for up to 24 mos (mean 22 mos) after the CHF was diagnosed using proportional hazards models including age, sex, EF, and 4 comorbidities (peripheral vascular disease, COPD, diabetes, CAD) that were associated with worse outcomes.

Results: Card Pts were younger (mean 66 vs 71 yrs, p<.0001), more often men (54% vs 46%, p<0.01), more often had definite CAD (63% vs 42%, p<0.001 ), and more frequently had a low (<45%) EF (63% vs 32%, p<0.002). Other comorbidities were similarly distributed. More Card Pts received ACE inhibitors (85% vs. 75%, p<0.007) and beta-blockers (40% vs 26%, p<0.003). Pts cared for by cardiologists were more likely to have an EF assessment (94% vs. 74%, p<0.001). Mortality (10.6% vs. 13.2%) and CV hospitalizations (28.3% vs 28.8%) were lower in the Card and Genl groups, respectively. By multivariate analysis low EF was the most significant predictor of death or CV hospitalizations (HR 1.99, CI 1.38-2.87, p<0.0003), and Card care was an independent predictor of better outcome (HR 0.66, CI 0.45-0.96, p<0.03).

Conclusions: Cardiology care at this early stage of CHF is associated with better compliance with guideline recommendations and a reduced risk of the composite outcome of death plus CV hospitalization.

Impact statement: This study suggests participation by cardiologists in the care of patients with recent onset heart failure managed in the outpatient setting is associated with reduced mortality and morbidity.