Resource Use and Survival of Patients Hospitalized with Congestive Heart Failure: Differences in Care by Specialty of the Attending Physician

1 February 2000 | Volume 132 Issue 3 | Pages 191-200

Background: Previous studies suggest that specialty care is more costly but may produce improved outcomes for patients with acute cardiac illnesses.

Objective: To determine whether patients with congestive heart failure who are cared for by cardiologists experienced differences in costs, care patterns, and survival compared with patients of generalists.

Design: Prospective cohort study.

Setting: 5 U.S. teaching hospitals between 1989 and 1994.

Patients: 1298 patients hospitalized with an exacerbation of congestive heart failure.

Measurements: Hospital costs; average daily Therapeutic Intervention Scoring System (TISS) score; and survival censored at 30, 180, and 365 days and 31 December 1994.

Results: Compared with patients of generalists, patients of cardiologists were younger (mean age, 63.3 and 71.4 years; P < 0.001) and had lower Acute Physiology Scores at the time of admission (35.1 and 36.7; P < 0.001) but were more likely to have a history of ventricular arrhythmias (21.0% and 10.2%; P < 0.001). At 6 months, 201 (27%) patients of cardiologists and 149 (27%) patients of generalists had died. After adjustment for sociodemographic characteristics and severity of illness, patients of cardiologists incurred costs that were 42.9% (95% CI, 27.8% to 59.8%) higher and average daily TISS scores that were 2.83 points (CI, 1.96 to 3.68 points) higher than those of patients of generalists. Patients of cardiologists were more likely to undergo right-heart catheterization (adjusted odds ratio, 2.9 [CI, 1.7 to 4.9]) or cardiac catheterization (adjusted odds ratio, 3.9 [CI, 2.4 to 6.2]) and had higher odds for transfer to an intensive care unit and electrocardiographic monitoring. Adjusted survival did not differ significantly between groups at 30 days; however, there was a trend toward improved survival among patients of cardiologists at 1 year (adjusted relative hazard, 0.82 [CI, 0.65 to 1.04]) and at maximum follow-up (adjusted relative hazard, 0.80 [CI, 0.66 to 0.96]).

Conclusions: In this observational study of patients hospitalized with congestive heart failure, cardiologist care was associated with greater costs and resource use and no difference in survival at 30 days of follow-up. Whether the trend toward better survival at longer follow-up represents differences in care or unadjusted illness severity is uncertain.

Author and Article Information

From Beth Israel Deaconess Medical Center, Boston, Massachusetts; University of Virginia School of Medicine, Charlottesville, Virginia; University of Tennessee College of Medicine, Chattanooga, Tennessee; University of California at San Francisco, San Francisco, California; Duke University Medical Center, Durham, North Carolina; MetroHealth Medical Center, Cleveland, Ohio; University of California at Los Angeles Medical Center, Los Angeles, California; Marshfield Clinic, Marshfield, Wisconsin; and Allegheny General Hospital, Pittsburgh, Pennsylvania.

Presented in part at the annual meeting of the Society of General Internal Medicine, Washington, D.C., 2 May 1997.

Acknowledgments: The authors thank Jane Soukup, MS, for assistance in assembling the database used for this paper.

Grant Support: By the Robert Wood Johnson Foundation. The opinions and findings contained in this manuscript are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation or their Board of Trustees.

Requests for Single Reprints: Andrew Auerbach, MD, MPH, Department of Medicine—Box 0120, University of California, San Francisco, San Francisco, CA 94143.

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Current Author Addresses: Drs. Auerbach and Goldman: Department of Medicine, Box 0120, University of California, San Francisco, San Francisco, CA 94143.

Drs. Hamel, Davis, and Phillips: Division of General Internal Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Libby 330, Boston, MA 02215.

Dr. Connors: University of Virginia Health Science Center, Box 600, Charlottesville, VA 22908.

Dr. Regueiro: Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212.

Dr. Desbiens: University of Tennessee College of Medicine—Chattanooga Unit, 921 East Third Street, Suite 400, Chattanooga, TN 37379.

Dr. Califf: Duke Clinical Research Institute, Durham, NC 27705.

Dr. Dawson: Center for Health Research and Policy, Case Western Reserve University at MetroHealth Medical Center, 2500 MetroHealth Drive, R222, Cleveland, OH 44109-1998.

Dr. Wenger: Department of Medicine, University of California at Los Angeles Medical Center, Los Angeles, CA 90095-1736.

Dr. Vidaillet: Department of Cardiology, Marshfield Clinic, Marshfield, WI 54449.

Author Contributions: Conception and design: A.D. Auerbach, M.B. Hamel, C.R. Regueiro, N. Desbiens, L. Goldman, R.M. Califf, N.V. Dawson, H. Vidaillet, R.S. Phillips.

Analysis and interpretation of the data: A.D. Auerbach, R.B. Davis, A.F. Connors, N. Desbiens, L. Goldman, R.M. Califf, N.V. Dawson, H. Vidaillet, R.S. Phillips.

Drafting of the article: A.D. Auerbach, R.S. Phillips.

Critical revision of the article for important intellectual content: A.D. Auerbach, M.B. Hamel, R.B. Davis, A.F. Connors, N. Desbiens, L. Goldman, R.M. Califf, N.V. Dawson, N. Wenger, H. Vidaillet, R.S. Phillips.

Final approval of the article: A.D. Auerbach, M.B. Hamel, R.B. Davis, A.F. Connors, N. Desbiens, L. Goldman, R.M. Califf, N.V. Dawson, N. Wenger, H. Vidaillet, R.S. Phillips.

Provision of study materials or patients: A.F. Connors, N. Desbiens, L. Goldman, R.M. Califf, N.V. Dawson, N. Wenger, H. Vidaillet, R.S. Phillips.

Statistical expertise: R.B. Davis, A.F. Connors.

Obtaining of funding: N. Desbiens, L. Goldman, R.M. Califf, H. Vidaillet, R.S. Phillips.

Administrative, technical, or logistic support: R.S. Phillips.

Collection and assembly of data: A.D. Auerbach, A.F. Connors, N. Desbiens, L. Goldman, R.M. Califf, N.V. Dawson, N. Wenger, H. Vidaillet, R.S. Phillips.