Feature: Cardiologists should team with PCPs for best HF patient outcomes
Using a collaborative approach to heart failure (HF) care increased the use of drug therapy and diagnostic testing, and patients fared better under this model as opposed to being treated by a primary care physician (PCP) alone, according to an analysis published Nov. 2 in Circulation.

Douglas S. Lee, MD, PhD, of the Toronto General Hospital in Ontario, Canada, and colleagues used the National Ambulatory Care Reporting System, which included data of patients discharged from Ontario emergency departments (EDs) between April 2004 and March 2007.

After analyzing 10,599 patients, Lee and colleagues found that getting collaborative care from both a PCP and a cardiologist can help improve cardiac conditions and outcomes.

“Because heart failure patients who are discharged home don’t necessarily get the rapid treatment and care that a hospitalized patient would get, we aimed to look at what type of physician care a patient got and what the outcomes were like,” Lee told Cardiovascular Business News.

“This is an area you can’t randomize in a trial—you can’t randomize a patient to not seeing a physician or cardiologist,” he said.

In that case, the researchers performed a propensity analysis that used observational data to compare 6,596 HF patients cared for by PCPs alone, 535 cared for by cardiologists, 1,478 cared for by both cardiologists and PCPs (collaborative care) and 1,990 patients who did not visit a physician within 30 days after a HF discharge.

What we found surprising was that one in five patients did not see any physician within 30 days of being discharged from the emergency department,” said Lee. “This was surprising because heart failure is a fairly serious condition that is associated with high mortality rates and high numbers of hospitalizations.”

Compared with those who did not visit any physician within 30 days of discharge, patients who were seen by a physician had an almost 25 percent reduction in mortality—those who saw both a cardiologist and a PCP had an additional 21 percent reduction in mortality, he said.

The results also depicted reductions in the number of repeat HF visits—either ED visits or hospitalizations. “There were major differences in outcomes according to what type of physician care patients received within the first 30 days of follow-up,” said Lee.

Interestingly, Lee and colleagues found that HF patients who underwent collaborative care were more often prescribed ACE inhibitors, beta-blockers, ARBs, anticoagulants and statins compared to the others. “In general their medical profile was very good in terms of treatment of heart failure,” added Lee. “They were offered more evidence-based therapies.”

The use of ACE inhibitors was 58.8 percent for those undergoing collaborative care versus 54.6 percent for those treated by a PCP alone. These rates for ARBs were 22.7 percent versus 18.1 percent, respectively.

Overall, collaborative care patients saw better cardiac outcomes. Lee said that this could be attributed to the fact that cardiologists were more likely to evaluate for left ventricular ejection fraction and were more likely to perform noninvasive testing or cardiac catheterizations to evaluate ischemia.

“We also know that heart failure patients have much comorbidity and there are non-cardiac reasons for death among heart failure patients. Improved care could stem from receiving better attention by the primary care physician,” said Lee. “If you’ve got care for the cardiovascular issues and for the non-cardiac issues in the collaborative care model, it will probably result in better outcomes.

“The ideal situation is if heart failure patients are being managed by their primary care physician and their cardiologist together,” said Lee. “Not everyone gets that sort of care. In some cases, a primary care physician may leave the care of heart failure patients in the hands of the cardiologist because heart failure care is getting more and more complex, but it’s very important that non-cardiovascular issues are treated by a primary care physician.”

Lee offered that creating rapid triage clinics or rapid response clinics, like the ones used to treat chest pain patients, could be useful in getting better outcomes for HF patients.

“Our study suggests that collaborative care, with both a cardiologist and a primary care physician, is probably the best model to ensure both ends of the spectrum are covered.”

The study was funded by the Canadian Institutes of Health Research.