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Outcomes of Patients With Acute Decompensated Heart Failure Managed by Cardiologists Versus Noncardiologists
Outcomes of Patients With Acute Decompensated Heart Failure Managed by Cardiologists Versus Noncardiologists Shanmugam Uthamalingam, MDa, Jagdesh Kandala, MDb, Vijairam Selvaraj, MDc,*, William Martin, MDd, Marlyn Daley, ARNPe, Eshan Patvardhan, MBBSf, Robert Capodilupo, MDe, Stephanie Moore, MDg, and James L. Januzzi Jr, MDg Physician practice patterns in the management of hospitalized acute decompensated heart failure (ADHF) patients may vary by specialty; comparative practice patterns in ADHF management and clinical outcomes as a function of provider type have not been well reported. We studied a total of 496 patients discharged with the principal diagnosis of ADHF to analyze practice patterns among 3 provider types (cardiologists, hospitalists, and nonhospitalists). We examined outcomes of death and rehospitalization for HF and adherence to the Joint Commission HF performance core measures. Cardiologists had the highest adherence in all 4 HF core measures compared with hospitalists and nonhospitalists. At 6 months, 6.0% of the patients cared by cardiologists died compared with 10.9% and 11.4% cared by hospitalist and nonhospitalists (p [ 0.12). Patients cared for by cardiologists had a significantly lower 6-month ADHF readmission rate (16.2%) compared with hospitalists (40.1%) and nonhospitalists (34.9%, p <0.001). In multivariate analysis, both hospitalist and nonhospitalist provider types were an independent predictor for 6-month ADHF-related readmission (hospitalists vs cardiologists, hazard ratioadjusted 3.01; 95% confidence interval 1.84 to 4.89, p <0.001; and nonhospitalists vs cardiologists, hazard ratioadjusted 2.07; 95% confidence interval 1.24 to 3.46, p [ 0.005). In conclusion, cardiologist-delivered ADHF care is associated with greater adherence to HF core measures and with significantly lower rates of adverse outcome compared with noncardiologists. Ó 2015 Elsevier Inc. All rights reserved. (Am J Cardiol 2015;115:466e471) Hospitalists solely care for admitted patients, and previous studies have suggested that acute decompensated heart failure (ADHF) patients managed by hospitalists have reduced hospital length of stay, care that is more closely adherent to quality of care and treatment guidelines and better postdischarge follow-up of patients compared with care delivered by nonhospitalists.1 Although previous studies suggest that ADHF patients managed by cardiologists tend to have better outcome measures compared with patients managed by generalists,2e6 differences in practice patterns between hospitalists, nonhospitalists, and cardiologists have not been well described in the literature. The aim of this study was to evaluate the demographics, clinical characteristics, and clinical outcomes of consecutive patients discharged from a large
a Division of Cardiology and cDepartment of Internal Medicine, Baystate Medical Center, Springfield, Massachusetts; bDivision of Cardiology, Sarver Heart Center, University of Arizona, Tucson, Arizona; dHospitalist Division, Dartmouth Hitchcock Clinic at Catholic Medical Center, Manchester, New Hampshire; eDivision of Cardiology, New England Heart Institute, Catholic Medical Center, Manchester, New Hampshire; fDivision of Cardiology, St Elizabeth Medical Center, Boston, Massachusetts; and g Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts. Manuscript received May 16, 2014; revised manuscript received and accepted November 11, 2014. See page 471 for disclosure information. Grant support: Dr. Januzzi reports receiving grant support from Roche Diagnostics, Siemens, and Critical Diagnostics. *Corresponding author: Tel: (413) 271-0421; fax: (413) 794-8075. E-mail address: [email protected] (V. Selvaraj).
0002-9149/14/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjcard.2014.11.034
urban-based community hospital with the principal diagnosis of ADHF by 3 provider types—cardiologists, hospitalists, and nonhospitalists. In addition, adherence to the Joint Commission HF core measures as a function of provider type in the setting of ADHF hospitalization was analyzed. Methods The study included analysis of consecutive patients discharged from a large urban-based community hospital, Catholic Medical Center, Manchester, New Hampshire, with primary discharge diagnosis of ADHF from January 2006 to December 2007. As we elected to analyze the provider type adherence to the Joint Commission HF core measures, the eligibility for the study included age 18 years and patients not discharged to an acute care hospital or transferred to acute rehabilitation facility or hospice. Patients who left against medical advice or died in the hospital (n ¼ 36) were excluded from the study. Thus, a total of 496 patients were included in the study. The study population was divided into 3 groups based on the discharging provider: cardiologists’ patients (n ¼ 148), hospitalists’ patients (n ¼ 182), and nonhospitalists’ patients (n ¼ 166). The hospitalists’ and nonhospitalists’ patients were managed solely by them, whereas cardiologists’ patients were cared for by a team of full-time cardiologists. Data collection was done by the investigators from the medical and electronic records of the patient’s initial presentation, progress notes, and the discharge day instructions including the discharge summary. Stage 3 or 4 kidney www.ajconline.org
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Table 1 Baseline characteristics of study population attended by different health care providers Variable
Cardiologists (N¼148)
Hospitalists (N¼ 182)
Non-Hospitalists (N ¼ 166)
P value
Age (years) Men White Coronary artery disease Hypertension Heart failure Atrial fibrillation Coronary artery bypass surgery Diabetes mellitus Dyslipidemia Chronic obstructive pulmonary disease Smoking LVEF 40% LVEF 50% LVEF 40% (mean SD) LVEF 50% (mean SD) Clinical / lab characteristics Heart rate (beats/min) Systolic Blood pressure (mm Hg) S3 gallop Rales Orthopnea Paroxysmal Nocturnal Dyspnea Jugular venous distension Stage III - V kidney disease NYHA III and IV Hemoglobin level (g/dL) (mean SD) Serum sodium (mmol / L) (mean SD) Blood urea nitrogen (mg/dL) Serum creatinine (mg/dL) Glomerular Filtration Rate(ml/min/1.73 m2) Serum BNP Intensive care unit hospital stay (days) Medical Insurance Medicare Medicaid Private Self pay and/or uninsured
70.4 13.3 60% 98% 71% 89% 34% 47% 37% 32% 80% 28% 74% 68% 27% 22.6 8.5 61.4 5.0
76.8 13.5 50% 98% 60% 88% 26% 43% 28% 40% 69% 33% 77% 49% 41% 25.5 10.3 61.6 5.7
77.4 11.9 48% 99% 63% 87% 37% 46% 27% 46% 66% 30% 63% 46% 45% 27.8 10.2 62.6 5.5
.001 .07 .30 .12 .77 .10 .70 .14 .03 .01 .63 .01 .03 .003 .003 .36
83 20 126 21 60% 90% 70% 87% 65% 43% 80% 12.9 2.1 138 4 25 (14-54) 1.3 (0.8-2.2) 52.0 (25.0 e 76.7) 791 (221 -2411) 12.1
92 23 131 35 47% 85% 62% 76% 69% 45% 60% 12.3 2.4 138 4 32 (15-74) 1.4 (0.9 e 3.1) 42.5 (21.0 e 77.0) 820 (235 e 2500) 5.3
86 23 134 28 55% 92% 52% 79% 70% 47% 63% 12.1 2.0 138 4 26 (14 e 59) 1.3 (0.8 e 2.5) 45.0 (22.1 e 76.9) 719 (271 e 2000) 4.1
.001 .07 .06 .07 .004 .01 .58 .81 .0001 .006 .66 .02 .13 .001 .56 .0001
56% 9% 33% 2%
71% 18% 2% 9%
73% 16% 4% 7%
.003 .04 .0001 .03
disease was diagnosed according to glomerular filtration rate in ml/min/1.73 m2 calculated by modification of diet in renal disease formula.7 Stage 3 and 4 kidney disease was considered when glomerular filtration rate was 30 to 59 ml/ min/1.73 m2 and 15 to 29 ml/min/1.73 m2, respectively. Catholic Medical Center is an approved Joint Commission performance system vendor for the Joint Commission HF failure core measure sets.8 Adherence to the core measures was analyzed based on the analysis of the health care provider’s medical records for adherence to HF core measure sets. These include1 assessment and documentation of left ventricular ejection fraction (LVEF) as a measure of left ventricular function before or during hospitalization or is planned for assessment after discharge2; prescription of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) for patients with left ventricular systolic dysfunction (LVEF 40%)3; provision of written discharge instruction or educational material regarding activity, weight, diet and fluid restriction, daily
weight monitoring, discharge medications, and follow-up appointment; and4 counseling on smoking cessation for cigarette smokers or who have smoked cigarettes within past 1 year of discharge from the hospital. To analyze the adherence of the provider type to the Joint Commission HF core measures, only the eligible patients for each item of the core measures were compared. Patients were followed for cardiac-related death or ADHF readmission from the day discharged from the hospital for up to a period of 6 months. The length of hospital stay and direct hospital cost for each hospital admission was provided by the hospital finance department. Cardiac-related death was identified as heart failure, cardiac arrest, or myocardial infarction. Mortality data were obtained from the death certificate issued by the primary care physician at the time of death and social security death index. The institutional review board at the Catholic Medical Center approved the study. Among the different provider types, the demographics, clinical characteristics, laboratory tests, and hemodynamics
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Table 2 Item by item adherence of the Joint Commission heart failure core measures among 3 providers (cardiologists, hospitalists and non- hospitalists) Joint Commission HF core measures
LVEF assessment* ACEI and / or ARB therapy† Discharge instructionsz Smoking cessationx
Provider adherence
P value
Cardiologists
Hospitalists
NonHospitalists
93% 96%
78% 92%
76% 91%
<0.001 0.67
100%
96%
90%
0.001
100%
94%
92%
0.02
ACEI ¼ angiotensin converting enzyme inhibitor; ARB ¼ angiotensin receptor blockade; LVEF ¼ left ventricular ejection fraction. * Eligible patients for cardiologists (n¼ 148), hospitalists (n¼182) and non-hospitalists (n¼166). † Eligible patients for cardiologists (n¼ 100), hospitalists (n¼90) and non-hospitalists (n¼76). z Eligible patients for cardiologists (n¼ 148), hospitalists (n¼182) and non-hospitalists (n¼166). x Eligible patients for cardiologists (n¼110), hospitalists (n¼140) and non-hospitalists (n¼105).
Figure 2. Cumulative 6-month acute decompensated HF readmission event rates for different provider types.
Table 3 Patients’ medications on discharge according to provider type Variables Digoxin
b blockers Oral loop diuretics Statin Coumadin ACEI /ARB IV diuretics / drip
Cardiologists Hospitalists Non-Hospitalists P value (N¼148) (N¼ 182) (N ¼ 166) 22% 87% 89% 68% 45% 77% 22%
31% 89% 85% 72% 40% 65% 3%
26% 74% 87% 58% 35% 72% 2%
.21 .0001 .93 .01 .17 .06 .0001
Figure 3. Cumulative 6-month cardiac-related death and/or readmission event rates for different provider types.
Figure 1. Cumulative 6-month cardiac-related death event rates for different provider types.
of the study population with analysis of variance and Kruskal-Wallis tests for continuous variables as appropriate and chi-square test for categorical variables were compared.
Associations between provider groups for compliance with the Joint Commission HF core measures were assessed using the chi-square test. Kaplan-Meier survival analysis was used to measure the 6-month cardiac-related mortality between the 3 provider types. Cox proportional hazards analysis was used for univariate and multivariate modeling of the ADHF-related readmission event rate and the composite of death and/or readmission event rate between the provider type pair: cardiologists versus hospitalists and cardiologists versus nonhospitalists. Variables included in the multivariate model include those found to be significant by univariate analysis; variables examined included age, gender, history of diabetes mellitus, history of HF, coronary artery disease and LVEF 40%, LVEF >50%, New York Heart Association
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Table 4 Predictors of 6 month rehospitalization for acute decompensated heart failure as a function of cardiologists versus hospitalists Variables
Univariate
Multivariate
Hazard ratio (95% CI) Treatment by Hospitalists (vs Cardiologists) Diabetes mellitus Prior heart failure Hemoglobin Blood Urea Nitrogen Creatinine
2.86 1.60 1.53 0.89 1.01 1.26
P value <0.001 0.013 0.003 0.016 0.003 0.001
(1.80-4.44) (1.40 to 1.89) (1.35 to 1.80) (0.81 to 0.98) (1.00 to 1.02) (1.10 to 1.44)
Hazard ratio (95% CI) 3.01 1.03 1.51 0.92 1.00 1.16
(1.84 (0.77 (1.33 (0.84 (0.99 (0.95
to to to to to to
P value
4.89) 1.43) 1.78) 1.01) 1.01) 1.41)
<0.001 0.19 0.002 0.09 0.54 0.12
Table 5 Predictors of 6 month rehospitalization for acute decompensated heart failure as a function of cardiologists versus non-hospitalists Variables
Univariate Hazard ratio (95% CI)
Treatment by Non- Hospitalists ( vs Cardiologists) Diabetes mellitus S3 gallop Systolic blood pressure Left Ventricular Ejection Fraction 40% Left Ventricular Ejection Fraction > 50%
2.39 1.56 1.73 1.01 1.68 0.61
(1.48 (1.31 (1.12 (1.00 (1.09 (0.39
to to to to to to
Multivariate P value
3.84) 1.72) 2.68) 1.01) 2.60) 0.95)
<0.001 0.02 0.01 0.02 0.02 0.03
Hazard ratio (95% C.I.) 2.07 1.12 1.68 1.00 1.29 0.97
(1.24 (0.62 (1.07 (0.99 (0.56 (0.42
to to to to to to
3.46) 1.54) 2.62) 1.01) 2.99) 2.23)
P value .005 0.15 0.02 0.21 0.54 0.95
Table 6 Length of hospital stay and hospital costs for different health care providers Variables
Cardiologists (95% C.I.)
Hospitalists (95% C.I.)
Non-hospitalists (95% C.I.)
6.70 (5.71 to 7.68) 8029 (7026 to 9032)
5.50 (4.9 to 6.11)* 7420 (6876 to 7964)†
5.24 (4.67 to 5.80)* 7166 (6575 to 7757 )†
Hospital length of stay (days) Cost (U.S. dollars) * p < 0.05 for comparison with cardiologists. † p > 0.05 for comparison with cardiologists.
functional class III and IV, hypertension, clinical signs and symptoms, blood urea nitrogen, serum creatinine, hemoglobin, and use of b blockers, ACEI, and/or ARB. Hazard ratios (HRs) and 95% confidence intervals (CIs) were reported. Multiple linear regression analysis was used to calculate the adjusted outcomes for the hospital length of stay and direct hospital costs between the provider types. Data analyses were performed using SPSS (PASW), version 17 for windows (SPSS, Inc., Chicago, Illinois); for all comparisons, p values 0.05 were considered statistically significant. Results The baseline clinical characteristics of the patients belonging to the 3 different provider types are listed in Table 1. Patients cared for by cardiologists tended to be younger, compared with those cared for by hospitalists and nonhospitalists (70.4 vs 76.8 vs 77.3 years, p <0.001), and were more likely to have more severe left ventricular dysfunction (mean LVEF 22.6% vs 25.5% vs 27.8%, p ¼ 0.003) and had New York Heart Association class III and IV
symptoms (79.9% vs 59.5% vs 63.3%, p <0.001), with a correspondingly higher prevalence of symptoms of orthopnea and paroxysmal nocturnal dyspnea. Adherences to different Joint Commission HF core measures among 3 different provider groups are listed in Table 2. Cardiologists had the highest adherence to the Joint Commission HF core measures for the LVEF assessment (93% vs 78% vs 76%, p <0.001), smoking cessation counseling (100% vs 94% vs 92%, p ¼ 0.02), and providing discharge instructions (100% vs 96% vs 90%, p ¼ 0.001). Although cardiologists had numerically higher adherence with either prescribing ACEI and/or ARB (or documenting contraindication to prescription, such as impaired renal function) compared with hospitalists and nonhospitalists (96% vs 92% vs 91%, p ¼ 0.67), the difference was not significantly different. A trend toward higher actual prescription of ACEI and/or ARB for patients discharged by cardiologists compared with hospitalists was found (77% vs 65%, p ¼ 0.06); however, no difference between cardiologists and nonhospitalists was found. Besides ACEI or ARB, at the time of discharge, a higher number of patients cared by cardiologists and hospitalists
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were discharged with the prescription of b blockers (87% vs 89% vs 74%, p <0.001) and statins (68% vs 72% vs 58%, p ¼ 0.01), compared with nonhospitalists. There were no differences in prescribing patterns for digoxin and loop diuretics in different provider types (Table 3). With respect to outcomes, despite having higher risk profiles, those patients with ADHF cared for by cardiologists had similar (if not numerically lower) 6-month cardiac-related death rates (Figure 1), compared with those cared for by hospitalists and nonhospitalists (6%, 10.9%, and 11.4%, respectively, p ¼ 0.12). When examining rates for recurrent ADHF over the 6 months of follow-up (Figure 2), patients treated by cardiologists were considerably less likely to be readmitted than those treated by hospitalists and nonhospitalists (16.2% vs 40.1% vs 34.9%, p <0.001). The composite outcome of death and/or readmission for ADHF at 6 months (Figure 3) was, thus, significantly lower in patients attended by cardiologists than hospitalists and nonhospitalists (20.2% vs 43.4% vs 40.3%, p <0.001). Table 4 details the risk-adjusted outcomes for ADHF rehospitalization as a function of care from cardiologists versus hospitalists. In univariate analysis, care by hospitalist, history of diabetes, history of HF, hemoglobin, blood urea nitrogen, and serum creatinine were all significant predictors for ADHF readmission; after adjustment for other variables, hospitalist provider type was an independent predictor to readmission of patient with ADHF (compared with cardiologists; HRadjusted 3.01; 95% CI 1.84 to 4.89, p <0.001) as was history of HF. In a similar fashion, Table 5 lists the risk-adjusted outcomes for rehospitalization as a function of care by cardiologists versus nonhospitalists. As with hospitalist care, after adjustment for other variables, nonhospitalist provider type was an independent predictor of ADHF readmission (HRadjusted 2.07; 95% CI 1.24 to 3.46, p ¼ 0.005) in addition to S3 gallop on physical examination. Table 6 lists the adjusted outcomes for hospital length of stay and direct hospital costs compared between 2 pairs: cardiologists versus hospitalists and cardiologists versus nonhospitalists. Patients cared for by cardiologists had a longer mean hospital length of stay (days) compared with those cared for by hospitalists (6.7 vs 5.5, p ¼ 0.03) and nonhospitalists (6.7 vs 5.24, p ¼ 0.02). Although mean hospital direct costs were higher in patients treated by cardiologists than the other provider types, this difference was not statistically significant. Discussion Our study demonstrates significant specialty-related differences in practice patterns in managing patients admitted to a large community hospital with ADHF. Cardiologists consistently showed greater adherence to HF core measures, compared with hospitalists and nonhospitalist providers. Those patients cared by the cardiologists had more severe HF, yet had lower 6-month event rates, compared with both hospitalists and nonhospitalists. Despite great advances in the understanding of optimal HF care, our results identify significant differences in the quality of care of ADHF patients when managed by noncardiologists.
To our knowledge, our study is the first to demonstrate specialty-related differences in managing patients with ADHF among cardiologists, hospitalists, and nonhospitalists. As the incidence and prevalence of HF is rising rapidly, it is reasonable to assert that care for patients with ADHF will increasingly be in the hands of noncardiologists and, hence, has unique importance because of that. Although the present study was not intended to identify the cause for the paradoxical finding that patients cared by cardiologists had generally more favorable event rates compared with hospitalists and nonhospitalists, these findings resemble similar outcomes that resulted from previous studies comparing cardiologists to family physicians.5 There may be several reasons for these to the findings observed in our study. The observation that patients cared for by noncardiologists had less severe HF symptoms, were more likely to have preserved left ventricular systolic dysfunction, and more likely to be elderly may (in part) explain increased readmission rates in these provider types compared with cardiologists as previously described,9,10 although these variables did not seem to be significant predictors of adverse outcomes in the presence of provider type in the model. The Joint Commission HF core measures have become an important benchmark for quality of care for patients hospitalized with ADHF. It has been suggested that increased adherence to the core measures may decrease short-term readmission and/or mortality rates.11e13 In our study, significant differences were observed in the adherence of 3 of 4 Joint Commission on Accreditation of Healthcare Organizations core measures by cardiologists, compared with other provider types, and it is not unreasonable to extrapolate adherence to the Joint Commission on Accreditation of Healthcare Organizations core measures to better outcomes. One reason for the greater adherence to the core measures might have been that patients cared for by cardiologists had significantly increased hospital length of stay (compared with those cared for by other provider types). However, it has been described previously that increased length of hospital stay does not necessarily increase adherence to core measures, whereas provider type does,14 an observation similar to our findings. An additional observation was more assiduous application of b blockers by cardiologists, compared with nonhospitalists. Given the clear, unmistakable benefit of these agents in HF, this may also help to explain superior outcomes in those patients cared for by cardiologists. Although numerically higher when delivered by cardiologists, the hospital cost in delivering care was not statistically different when given by cardiologists versus other provider types. The observed differences of relatively higher hospital costs in patients treated by cardiologists may be because of increased proportion of their patients admitted to the intensive care unit, more use of intravenous medications, and a longer length of hospital stay as has been suggested previously.15 However, in contrast with other data,16 no significant differences in cost outlay was present in provider types after adjusting hospital costs for clinical signs and symptoms, laboratory characteristics, hospital length of stay, other existing multiple comorbidities provider type, and the location of care in the hospital. The study has few limitations. It was a nonrandomized study, and patients were not matched for baseline covariates.
Heart Failure/Heart Failure Outcomes of Patients Managed by Different Specialists
However, the data reflect the experience of every day clinical practice and as such are reflective of current practices. The differences in patient demographics in those cared for by hospitalists or nonhospitalists (more elderly, more medical co-morbidities) may explain the higher rehospitalization rates; however, despite these differences, those cared for by cardiologists had higher risk features in HF (e.g., lower LVEF). Acknowledgment: The authors acknowledge the invaluable assistance of Cynthia David, MLS, MPS. Disclosures Dr. Januzzi is supported in part by the Balson scholar award. The authors have no conflicts of interest to disclose. 1. Reis SE, Holubkov R, Edmundowicz D, McNamara DM, Zell KA, Detre KM, Feldman AM. Treatment of patients admitted to the hospital with congestive heart failure: specialty-related disparities in practice patterns and outcomes. J Am Coll Cardiol 1997;30:733e738. 2. Roytman MM, Thomas SM, Jiang CS. Comparison of practice patterns of hospitalists and community physicians in the care of patients with congestive heart failure. J Hosp Med 2008;3:35e41. 3. Go AS, Rao RK, Dauterman KW, Massie BM. A systematic review of the effects of physician specialty on the treatment of coronary disease and heart failure in the United States. Am J Med 2000;108:216e226. 4. Jong P, Gong Y, Liu PP, Austin PC, Lee DS, Tu JV. Care and outcomes of patients newly hospitalized for heart failure in the community treated by cardiologists compared with other specialists. Circulation 2003;108:184e191. 5. Vasilevskis EE, Meltzer D, Schnipper J, Kaboli P, Wetterneck T, Gonzales D, Arora V, Zhang J, Auerbach AD. Quality of care for decompensated heart failure: comparable performance between academic hospitalists and non-hospitalists. J Gen Intern Med 2008;23: 1399e1406. 6. Philbin EF, Jenkins PL. Differences between patients with heart failure treated by cardiologists, internists, family physicians, and other physicians: analysis of a large, statewide database. Am Heart J 2000;139: 491e496.
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7. Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med 1999;130:461e470. 8. Joint Commission on Accreditation of Healthcare Organizations. Ongoing Activities: 2000 to 2004 Standardization of Metrics. Available at: http:// www.jointcommission.org/specifications_manual_for_national_hospital_ inpatient_quality_measures.aspx. Accessed on August 10, 2014. 9. Philbin EF, Rocco TA Jr, Lindenmuth NW, Ulrich K, Jenkins PL. Systolic versus diastolic heart failure in community practice: clinical features, outcomes, and the use of angiotensin-converting enzyme inhibitors. Am J Med 2000;109:605e613. 10. Tsutsui H, Tsuchihashi M, Takeshita A. Mortality and readmission of hospitalized patients with congestive heart failure and preserved versus depressed systolic function. Am J Cardiol 2001;88:530e533. 11. Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, O’Connor CM, Pieper K, Sun JL, Yancy C, Young JB; OPTIMIZE-HF Investigators and Hospitals. Association between performance measures and clinical outcomes for patients hospitalized with heart failure. JAMA 2007;297:61e70. 12. Kfoury AG, French TK, Horne BD, Rasmusson KD, Lappe DL, Rimmasch HL, Roberts CA, Evans RS, Muhlestein JB, Anderson JL, Renlund DG. Incremental survival benefit with adherence to standardized heart failure core measures: a performance evaluation study of 2958 patients. J Card Fail 2008;14:95e102. 13. VanSuch M, Naessens JM, Stroebel RJ, Huddleston JM, Williams AR. Effect of discharge instructions on readmission of hospitalised patients with heart failure: do all of the Joint Commission on Accreditation of Healthcare Organizations heart failure core measures reflect better care? Qual Saf Health Care 2006;15:414e417. 14. Harjai KJ, Boulos LM, Smart FW, Turgut T, Krousel-Wood MA, Stapleton DD, Mehra MR, Murgo JP, Ventura HO. Effects of caregiver specialty on cost and clinical outcomes following hospitalization for heart failure. Am J Cardiol 1998;82:82e85. 15. Philbin EF, McCullough PA, Dec GW, DiSalvo TG. Length of stay and procedure utilization are the major determinants of hospital charges for heart failure. Clin Cardiol 2001;24:56e62. 16. Auerbach AD, Hamel MB, Davis RB, Connors AF Jr, Requeiro C, Desbiens N, Goldman L, Califf RM, Dawson NV, Wenger N, Vidaillet H, Phillips RS. Resource use and survival of patients hospitalized with congestive heart failure: differences in care by specialty of the attending physician. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Ann Intern Med 2000;132:191e200.
a Division of Cardiology and cDepartment of Internal Medicine, Baystate Medical Center, Springfield, Massachusetts; bDivision of Cardiology, Sarver Heart Center, University of Arizona, Tucson, Arizona; dHospitalist Division, Dartmouth Hitchcock Clinic at Catholic Medical Center, Manchester, New Hampshire; eDivision of Cardiology, New England Heart Institute, Catholic Medical Center, Manchester, New Hampshire; fDivision of Cardiology, St Elizabeth Medical Center, Boston, Massachusetts; and g Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts. Manuscript received May 16, 2014; revised manuscript received and accepted November 11, 2014. See page 471 for disclosure information. Grant support: Dr. Januzzi reports receiving grant support from Roche Diagnostics, Siemens, and Critical Diagnostics. *Corresponding author: Tel: (413) 271-0421; fax: (413) 794-8075. E-mail address: [email protected] (V. Selvaraj).
0002-9149/14/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjcard.2014.11.034
urban-based community hospital with the principal diagnosis of ADHF by 3 provider types—cardiologists, hospitalists, and nonhospitalists. In addition, adherence to the Joint Commission HF core measures as a function of provider type in the setting of ADHF hospitalization was analyzed. Methods The study included analysis of consecutive patients discharged from a large urban-based community hospital, Catholic Medical Center, Manchester, New Hampshire, with primary discharge diagnosis of ADHF from January 2006 to December 2007. As we elected to analyze the provider type adherence to the Joint Commission HF core measures, the eligibility for the study included age 18 years and patients not discharged to an acute care hospital or transferred to acute rehabilitation facility or hospice. Patients who left against medical advice or died in the hospital (n ¼ 36) were excluded from the study. Thus, a total of 496 patients were included in the study. The study population was divided into 3 groups based on the discharging provider: cardiologists’ patients (n ¼ 148), hospitalists’ patients (n ¼ 182), and nonhospitalists’ patients (n ¼ 166). The hospitalists’ and nonhospitalists’ patients were managed solely by them, whereas cardiologists’ patients were cared for by a team of full-time cardiologists. Data collection was done by the investigators from the medical and electronic records of the patient’s initial presentation, progress notes, and the discharge day instructions including the discharge summary. Stage 3 or 4 kidney www.ajconline.org
Heart Failure/Heart Failure Outcomes of Patients Managed by Different Specialists
467
Table 1 Baseline characteristics of study population attended by different health care providers Variable
Cardiologists (N¼148)
Hospitalists (N¼ 182)
Non-Hospitalists (N ¼ 166)
P value
Age (years) Men White Coronary artery disease Hypertension Heart failure Atrial fibrillation Coronary artery bypass surgery Diabetes mellitus Dyslipidemia Chronic obstructive pulmonary disease Smoking LVEF 40% LVEF 50% LVEF 40% (mean SD) LVEF 50% (mean SD) Clinical / lab characteristics Heart rate (beats/min) Systolic Blood pressure (mm Hg) S3 gallop Rales Orthopnea Paroxysmal Nocturnal Dyspnea Jugular venous distension Stage III - V kidney disease NYHA III and IV Hemoglobin level (g/dL) (mean SD) Serum sodium (mmol / L) (mean SD) Blood urea nitrogen (mg/dL) Serum creatinine (mg/dL) Glomerular Filtration Rate(ml/min/1.73 m2) Serum BNP Intensive care unit hospital stay (days) Medical Insurance Medicare Medicaid Private Self pay and/or uninsured
70.4 13.3 60% 98% 71% 89% 34% 47% 37% 32% 80% 28% 74% 68% 27% 22.6 8.5 61.4 5.0
76.8 13.5 50% 98% 60% 88% 26% 43% 28% 40% 69% 33% 77% 49% 41% 25.5 10.3 61.6 5.7
77.4 11.9 48% 99% 63% 87% 37% 46% 27% 46% 66% 30% 63% 46% 45% 27.8 10.2 62.6 5.5
.001 .07 .30 .12 .77 .10 .70 .14 .03 .01 .63 .01 .03 .003 .003 .36
83 20 126 21 60% 90% 70% 87% 65% 43% 80% 12.9 2.1 138 4 25 (14-54) 1.3 (0.8-2.2) 52.0 (25.0 e 76.7) 791 (221 -2411) 12.1
92 23 131 35 47% 85% 62% 76% 69% 45% 60% 12.3 2.4 138 4 32 (15-74) 1.4 (0.9 e 3.1) 42.5 (21.0 e 77.0) 820 (235 e 2500) 5.3
86 23 134 28 55% 92% 52% 79% 70% 47% 63% 12.1 2.0 138 4 26 (14 e 59) 1.3 (0.8 e 2.5) 45.0 (22.1 e 76.9) 719 (271 e 2000) 4.1
.001 .07 .06 .07 .004 .01 .58 .81 .0001 .006 .66 .02 .13 .001 .56 .0001
56% 9% 33% 2%
71% 18% 2% 9%
73% 16% 4% 7%
.003 .04 .0001 .03
disease was diagnosed according to glomerular filtration rate in ml/min/1.73 m2 calculated by modification of diet in renal disease formula.7 Stage 3 and 4 kidney disease was considered when glomerular filtration rate was 30 to 59 ml/ min/1.73 m2 and 15 to 29 ml/min/1.73 m2, respectively. Catholic Medical Center is an approved Joint Commission performance system vendor for the Joint Commission HF failure core measure sets.8 Adherence to the core measures was analyzed based on the analysis of the health care provider’s medical records for adherence to HF core measure sets. These include1 assessment and documentation of left ventricular ejection fraction (LVEF) as a measure of left ventricular function before or during hospitalization or is planned for assessment after discharge2; prescription of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) for patients with left ventricular systolic dysfunction (LVEF 40%)3; provision of written discharge instruction or educational material regarding activity, weight, diet and fluid restriction, daily
weight monitoring, discharge medications, and follow-up appointment; and4 counseling on smoking cessation for cigarette smokers or who have smoked cigarettes within past 1 year of discharge from the hospital. To analyze the adherence of the provider type to the Joint Commission HF core measures, only the eligible patients for each item of the core measures were compared. Patients were followed for cardiac-related death or ADHF readmission from the day discharged from the hospital for up to a period of 6 months. The length of hospital stay and direct hospital cost for each hospital admission was provided by the hospital finance department. Cardiac-related death was identified as heart failure, cardiac arrest, or myocardial infarction. Mortality data were obtained from the death certificate issued by the primary care physician at the time of death and social security death index. The institutional review board at the Catholic Medical Center approved the study. Among the different provider types, the demographics, clinical characteristics, laboratory tests, and hemodynamics
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Table 2 Item by item adherence of the Joint Commission heart failure core measures among 3 providers (cardiologists, hospitalists and non- hospitalists) Joint Commission HF core measures
LVEF assessment* ACEI and / or ARB therapy† Discharge instructionsz Smoking cessationx
Provider adherence
P value
Cardiologists
Hospitalists
NonHospitalists
93% 96%
78% 92%
76% 91%
<0.001 0.67
100%
96%
90%
0.001
100%
94%
92%
0.02
ACEI ¼ angiotensin converting enzyme inhibitor; ARB ¼ angiotensin receptor blockade; LVEF ¼ left ventricular ejection fraction. * Eligible patients for cardiologists (n¼ 148), hospitalists (n¼182) and non-hospitalists (n¼166). † Eligible patients for cardiologists (n¼ 100), hospitalists (n¼90) and non-hospitalists (n¼76). z Eligible patients for cardiologists (n¼ 148), hospitalists (n¼182) and non-hospitalists (n¼166). x Eligible patients for cardiologists (n¼110), hospitalists (n¼140) and non-hospitalists (n¼105).
Figure 2. Cumulative 6-month acute decompensated HF readmission event rates for different provider types.
Table 3 Patients’ medications on discharge according to provider type Variables Digoxin
b blockers Oral loop diuretics Statin Coumadin ACEI /ARB IV diuretics / drip
Cardiologists Hospitalists Non-Hospitalists P value (N¼148) (N¼ 182) (N ¼ 166) 22% 87% 89% 68% 45% 77% 22%
31% 89% 85% 72% 40% 65% 3%
26% 74% 87% 58% 35% 72% 2%
.21 .0001 .93 .01 .17 .06 .0001
Figure 3. Cumulative 6-month cardiac-related death and/or readmission event rates for different provider types.
Figure 1. Cumulative 6-month cardiac-related death event rates for different provider types.
of the study population with analysis of variance and Kruskal-Wallis tests for continuous variables as appropriate and chi-square test for categorical variables were compared.
Associations between provider groups for compliance with the Joint Commission HF core measures were assessed using the chi-square test. Kaplan-Meier survival analysis was used to measure the 6-month cardiac-related mortality between the 3 provider types. Cox proportional hazards analysis was used for univariate and multivariate modeling of the ADHF-related readmission event rate and the composite of death and/or readmission event rate between the provider type pair: cardiologists versus hospitalists and cardiologists versus nonhospitalists. Variables included in the multivariate model include those found to be significant by univariate analysis; variables examined included age, gender, history of diabetes mellitus, history of HF, coronary artery disease and LVEF 40%, LVEF >50%, New York Heart Association
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Table 4 Predictors of 6 month rehospitalization for acute decompensated heart failure as a function of cardiologists versus hospitalists Variables
Univariate
Multivariate
Hazard ratio (95% CI) Treatment by Hospitalists (vs Cardiologists) Diabetes mellitus Prior heart failure Hemoglobin Blood Urea Nitrogen Creatinine
2.86 1.60 1.53 0.89 1.01 1.26
P value <0.001 0.013 0.003 0.016 0.003 0.001
(1.80-4.44) (1.40 to 1.89) (1.35 to 1.80) (0.81 to 0.98) (1.00 to 1.02) (1.10 to 1.44)
Hazard ratio (95% CI) 3.01 1.03 1.51 0.92 1.00 1.16
(1.84 (0.77 (1.33 (0.84 (0.99 (0.95
to to to to to to
P value
4.89) 1.43) 1.78) 1.01) 1.01) 1.41)
<0.001 0.19 0.002 0.09 0.54 0.12
Table 5 Predictors of 6 month rehospitalization for acute decompensated heart failure as a function of cardiologists versus non-hospitalists Variables
Univariate Hazard ratio (95% CI)
Treatment by Non- Hospitalists ( vs Cardiologists) Diabetes mellitus S3 gallop Systolic blood pressure Left Ventricular Ejection Fraction 40% Left Ventricular Ejection Fraction > 50%
2.39 1.56 1.73 1.01 1.68 0.61
(1.48 (1.31 (1.12 (1.00 (1.09 (0.39
to to to to to to
Multivariate P value
3.84) 1.72) 2.68) 1.01) 2.60) 0.95)
<0.001 0.02 0.01 0.02 0.02 0.03
Hazard ratio (95% C.I.) 2.07 1.12 1.68 1.00 1.29 0.97
(1.24 (0.62 (1.07 (0.99 (0.56 (0.42
to to to to to to
3.46) 1.54) 2.62) 1.01) 2.99) 2.23)
P value .005 0.15 0.02 0.21 0.54 0.95
Table 6 Length of hospital stay and hospital costs for different health care providers Variables
Cardiologists (95% C.I.)
Hospitalists (95% C.I.)
Non-hospitalists (95% C.I.)
6.70 (5.71 to 7.68) 8029 (7026 to 9032)
5.50 (4.9 to 6.11)* 7420 (6876 to 7964)†
5.24 (4.67 to 5.80)* 7166 (6575 to 7757 )†
Hospital length of stay (days) Cost (U.S. dollars) * p < 0.05 for comparison with cardiologists. † p > 0.05 for comparison with cardiologists.
functional class III and IV, hypertension, clinical signs and symptoms, blood urea nitrogen, serum creatinine, hemoglobin, and use of b blockers, ACEI, and/or ARB. Hazard ratios (HRs) and 95% confidence intervals (CIs) were reported. Multiple linear regression analysis was used to calculate the adjusted outcomes for the hospital length of stay and direct hospital costs between the provider types. Data analyses were performed using SPSS (PASW), version 17 for windows (SPSS, Inc., Chicago, Illinois); for all comparisons, p values 0.05 were considered statistically significant. Results The baseline clinical characteristics of the patients belonging to the 3 different provider types are listed in Table 1. Patients cared for by cardiologists tended to be younger, compared with those cared for by hospitalists and nonhospitalists (70.4 vs 76.8 vs 77.3 years, p <0.001), and were more likely to have more severe left ventricular dysfunction (mean LVEF 22.6% vs 25.5% vs 27.8%, p ¼ 0.003) and had New York Heart Association class III and IV
symptoms (79.9% vs 59.5% vs 63.3%, p <0.001), with a correspondingly higher prevalence of symptoms of orthopnea and paroxysmal nocturnal dyspnea. Adherences to different Joint Commission HF core measures among 3 different provider groups are listed in Table 2. Cardiologists had the highest adherence to the Joint Commission HF core measures for the LVEF assessment (93% vs 78% vs 76%, p <0.001), smoking cessation counseling (100% vs 94% vs 92%, p ¼ 0.02), and providing discharge instructions (100% vs 96% vs 90%, p ¼ 0.001). Although cardiologists had numerically higher adherence with either prescribing ACEI and/or ARB (or documenting contraindication to prescription, such as impaired renal function) compared with hospitalists and nonhospitalists (96% vs 92% vs 91%, p ¼ 0.67), the difference was not significantly different. A trend toward higher actual prescription of ACEI and/or ARB for patients discharged by cardiologists compared with hospitalists was found (77% vs 65%, p ¼ 0.06); however, no difference between cardiologists and nonhospitalists was found. Besides ACEI or ARB, at the time of discharge, a higher number of patients cared by cardiologists and hospitalists
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were discharged with the prescription of b blockers (87% vs 89% vs 74%, p <0.001) and statins (68% vs 72% vs 58%, p ¼ 0.01), compared with nonhospitalists. There were no differences in prescribing patterns for digoxin and loop diuretics in different provider types (Table 3). With respect to outcomes, despite having higher risk profiles, those patients with ADHF cared for by cardiologists had similar (if not numerically lower) 6-month cardiac-related death rates (Figure 1), compared with those cared for by hospitalists and nonhospitalists (6%, 10.9%, and 11.4%, respectively, p ¼ 0.12). When examining rates for recurrent ADHF over the 6 months of follow-up (Figure 2), patients treated by cardiologists were considerably less likely to be readmitted than those treated by hospitalists and nonhospitalists (16.2% vs 40.1% vs 34.9%, p <0.001). The composite outcome of death and/or readmission for ADHF at 6 months (Figure 3) was, thus, significantly lower in patients attended by cardiologists than hospitalists and nonhospitalists (20.2% vs 43.4% vs 40.3%, p <0.001). Table 4 details the risk-adjusted outcomes for ADHF rehospitalization as a function of care from cardiologists versus hospitalists. In univariate analysis, care by hospitalist, history of diabetes, history of HF, hemoglobin, blood urea nitrogen, and serum creatinine were all significant predictors for ADHF readmission; after adjustment for other variables, hospitalist provider type was an independent predictor to readmission of patient with ADHF (compared with cardiologists; HRadjusted 3.01; 95% CI 1.84 to 4.89, p <0.001) as was history of HF. In a similar fashion, Table 5 lists the risk-adjusted outcomes for rehospitalization as a function of care by cardiologists versus nonhospitalists. As with hospitalist care, after adjustment for other variables, nonhospitalist provider type was an independent predictor of ADHF readmission (HRadjusted 2.07; 95% CI 1.24 to 3.46, p ¼ 0.005) in addition to S3 gallop on physical examination. Table 6 lists the adjusted outcomes for hospital length of stay and direct hospital costs compared between 2 pairs: cardiologists versus hospitalists and cardiologists versus nonhospitalists. Patients cared for by cardiologists had a longer mean hospital length of stay (days) compared with those cared for by hospitalists (6.7 vs 5.5, p ¼ 0.03) and nonhospitalists (6.7 vs 5.24, p ¼ 0.02). Although mean hospital direct costs were higher in patients treated by cardiologists than the other provider types, this difference was not statistically significant. Discussion Our study demonstrates significant specialty-related differences in practice patterns in managing patients admitted to a large community hospital with ADHF. Cardiologists consistently showed greater adherence to HF core measures, compared with hospitalists and nonhospitalist providers. Those patients cared by the cardiologists had more severe HF, yet had lower 6-month event rates, compared with both hospitalists and nonhospitalists. Despite great advances in the understanding of optimal HF care, our results identify significant differences in the quality of care of ADHF patients when managed by noncardiologists.
To our knowledge, our study is the first to demonstrate specialty-related differences in managing patients with ADHF among cardiologists, hospitalists, and nonhospitalists. As the incidence and prevalence of HF is rising rapidly, it is reasonable to assert that care for patients with ADHF will increasingly be in the hands of noncardiologists and, hence, has unique importance because of that. Although the present study was not intended to identify the cause for the paradoxical finding that patients cared by cardiologists had generally more favorable event rates compared with hospitalists and nonhospitalists, these findings resemble similar outcomes that resulted from previous studies comparing cardiologists to family physicians.5 There may be several reasons for these to the findings observed in our study. The observation that patients cared for by noncardiologists had less severe HF symptoms, were more likely to have preserved left ventricular systolic dysfunction, and more likely to be elderly may (in part) explain increased readmission rates in these provider types compared with cardiologists as previously described,9,10 although these variables did not seem to be significant predictors of adverse outcomes in the presence of provider type in the model. The Joint Commission HF core measures have become an important benchmark for quality of care for patients hospitalized with ADHF. It has been suggested that increased adherence to the core measures may decrease short-term readmission and/or mortality rates.11e13 In our study, significant differences were observed in the adherence of 3 of 4 Joint Commission on Accreditation of Healthcare Organizations core measures by cardiologists, compared with other provider types, and it is not unreasonable to extrapolate adherence to the Joint Commission on Accreditation of Healthcare Organizations core measures to better outcomes. One reason for the greater adherence to the core measures might have been that patients cared for by cardiologists had significantly increased hospital length of stay (compared with those cared for by other provider types). However, it has been described previously that increased length of hospital stay does not necessarily increase adherence to core measures, whereas provider type does,14 an observation similar to our findings. An additional observation was more assiduous application of b blockers by cardiologists, compared with nonhospitalists. Given the clear, unmistakable benefit of these agents in HF, this may also help to explain superior outcomes in those patients cared for by cardiologists. Although numerically higher when delivered by cardiologists, the hospital cost in delivering care was not statistically different when given by cardiologists versus other provider types. The observed differences of relatively higher hospital costs in patients treated by cardiologists may be because of increased proportion of their patients admitted to the intensive care unit, more use of intravenous medications, and a longer length of hospital stay as has been suggested previously.15 However, in contrast with other data,16 no significant differences in cost outlay was present in provider types after adjusting hospital costs for clinical signs and symptoms, laboratory characteristics, hospital length of stay, other existing multiple comorbidities provider type, and the location of care in the hospital. The study has few limitations. It was a nonrandomized study, and patients were not matched for baseline covariates.
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However, the data reflect the experience of every day clinical practice and as such are reflective of current practices. The differences in patient demographics in those cared for by hospitalists or nonhospitalists (more elderly, more medical co-morbidities) may explain the higher rehospitalization rates; however, despite these differences, those cared for by cardiologists had higher risk features in HF (e.g., lower LVEF). Acknowledgment: The authors acknowledge the invaluable assistance of Cynthia David, MLS, MPS. Disclosures Dr. Januzzi is supported in part by the Balson scholar award. The authors have no conflicts of interest to disclose. 1. Reis SE, Holubkov R, Edmundowicz D, McNamara DM, Zell KA, Detre KM, Feldman AM. Treatment of patients admitted to the hospital with congestive heart failure: specialty-related disparities in practice patterns and outcomes. J Am Coll Cardiol 1997;30:733e738. 2. Roytman MM, Thomas SM, Jiang CS. Comparison of practice patterns of hospitalists and community physicians in the care of patients with congestive heart failure. J Hosp Med 2008;3:35e41. 3. Go AS, Rao RK, Dauterman KW, Massie BM. A systematic review of the effects of physician specialty on the treatment of coronary disease and heart failure in the United States. Am J Med 2000;108:216e226. 4. Jong P, Gong Y, Liu PP, Austin PC, Lee DS, Tu JV. Care and outcomes of patients newly hospitalized for heart failure in the community treated by cardiologists compared with other specialists. Circulation 2003;108:184e191. 5. Vasilevskis EE, Meltzer D, Schnipper J, Kaboli P, Wetterneck T, Gonzales D, Arora V, Zhang J, Auerbach AD. Quality of care for decompensated heart failure: comparable performance between academic hospitalists and non-hospitalists. J Gen Intern Med 2008;23: 1399e1406. 6. Philbin EF, Jenkins PL. Differences between patients with heart failure treated by cardiologists, internists, family physicians, and other physicians: analysis of a large, statewide database. Am Heart J 2000;139: 491e496.
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7. Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med 1999;130:461e470. 8. Joint Commission on Accreditation of Healthcare Organizations. Ongoing Activities: 2000 to 2004 Standardization of Metrics. Available at: http:// www.jointcommission.org/specifications_manual_for_national_hospital_ inpatient_quality_measures.aspx. Accessed on August 10, 2014. 9. Philbin EF, Rocco TA Jr, Lindenmuth NW, Ulrich K, Jenkins PL. Systolic versus diastolic heart failure in community practice: clinical features, outcomes, and the use of angiotensin-converting enzyme inhibitors. Am J Med 2000;109:605e613. 10. Tsutsui H, Tsuchihashi M, Takeshita A. Mortality and readmission of hospitalized patients with congestive heart failure and preserved versus depressed systolic function. Am J Cardiol 2001;88:530e533. 11. Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, O’Connor CM, Pieper K, Sun JL, Yancy C, Young JB; OPTIMIZE-HF Investigators and Hospitals. Association between performance measures and clinical outcomes for patients hospitalized with heart failure. JAMA 2007;297:61e70. 12. Kfoury AG, French TK, Horne BD, Rasmusson KD, Lappe DL, Rimmasch HL, Roberts CA, Evans RS, Muhlestein JB, Anderson JL, Renlund DG. Incremental survival benefit with adherence to standardized heart failure core measures: a performance evaluation study of 2958 patients. J Card Fail 2008;14:95e102. 13. VanSuch M, Naessens JM, Stroebel RJ, Huddleston JM, Williams AR. Effect of discharge instructions on readmission of hospitalised patients with heart failure: do all of the Joint Commission on Accreditation of Healthcare Organizations heart failure core measures reflect better care? Qual Saf Health Care 2006;15:414e417. 14. Harjai KJ, Boulos LM, Smart FW, Turgut T, Krousel-Wood MA, Stapleton DD, Mehra MR, Murgo JP, Ventura HO. Effects of caregiver specialty on cost and clinical outcomes following hospitalization for heart failure. Am J Cardiol 1998;82:82e85. 15. Philbin EF, McCullough PA, Dec GW, DiSalvo TG. Length of stay and procedure utilization are the major determinants of hospital charges for heart failure. Clin Cardiol 2001;24:56e62. 16. Auerbach AD, Hamel MB, Davis RB, Connors AF Jr, Requeiro C, Desbiens N, Goldman L, Califf RM, Dawson NV, Wenger N, Vidaillet H, Phillips RS. Resource use and survival of patients hospitalized with congestive heart failure: differences in care by specialty of the attending physician. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Ann Intern Med 2000;132:191e200.