JACC in a Flash: For HF Patients, Call a Cardiologist Not Quite a No-Brainer

In response to the fee-for-service Medicare program, many hospitals have adopted the hospitalist model in an attempt to reduce patients' length of stay for HF and avoid penalty fees for increases in mortality and readmission. Hospitalists are charged with caring for a wide range of general medical patients and, increasingly, for patients traditionally cared for by subspecialists. Previous research has shown that cardiologist care is associated with improved adherence to evidence-based therapies and improved outcomes compared to the generalist care model, but little is known about the potential advantages of the hospitalist model over the cardiologist model.

In a study appearing in JACC, Robb D. Kociol, MD, from Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, and colleagues compared the hospitalist and cardiologist models specifically in a population of HF patients. Using data from the American Heart Association's Get with the Guidelines-Heart Failure registry and Medicare claims data, Kociol et al. analyzed outcomes and adherence to quality measures of each model, in a total population of 31,505 Medicare beneficiaries across 166 hospitals.

Typically, hospitals in the lowest quartile of hospitalist use had fewer beds and fewer annual median admissions of HF patients; in the middle two quartiles, hospitals were larger and had more HF admissions. Average rates of hospitalist use from the lowest to the highest quartile were: 0%, 7.9%, 18.3%, and 37.0%. As expected, the lowest rates of cardiologist use for HF patients occurred in hospitals in the highest quartile of hospitalist use.

Patient-level outcomes and adherence to established and emerging HF performance measures were basically similar between both models. After adjustment for patient and hospital characteristics, there was a statistically significant, though small, association between each 10% increase in hospital use and 30-day mortality (risk ratio = 1.03; p = 0.02); on the other hand, use of hospitalists was associated with a reduction in median length of stay of 0.09 days.

Ultimately, increasing use of cardiologists in the care of patients with HF was not associated with improvement in outcomes (30-day mortality, 30-day readmission, or length-of-stay after adjustment), but was helpful in increasing adherence to established HF quality measures in hospitals with greater use of hospitalists.

"Our findings highlight the need for studies to determine optimal models of care for patients hospitalized with heart failure," the authors wrote. The variability in the use of hospitalists and cardiologists suggests that considerable uncertainty exists about how to best care for hospitalized HF patients, but, Dr. Kociol and authors added, "the results suggest that comanagement by hospitalists and cardiologists may help to improve adherence to some quality measures, but it remains unclear what care model improves 30-day clinical outcomes."

Kociol RD, Hammill BG, Fonarow GC, et al. J Am Coll Cardiol. 2013 September 11. [Epub ahead of print]

Keywords: Fee-for-Service Plans, Heart Failure, Medicare, Hospitalists, Length of Stay

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