Is specialty care associated with improved survival of patients with congestive heart failure?
BACKGROUND
Implementation of the complex treatment strategies that have been shown to improve survival of patients with congestive heart failure (CHF) may require certain expertise. We wanted to examine the association between pattern of outpatient care and survival of patients with CHF.


METHODS
In a retrospective cohort study conducted with national Veterans Health Administration (VHA) databases, we examined the association between the pattern of outpatient care and survival in 11,661 patients discharged from VA hospitals between October 1, 1991, and September 30, 1992, with the primary diagnosis of CHF (cohort 1). Patients were divided into 4 groups, on the basis of their pattern of outpatient care over a 12-month period after discharge: 1) general medicine clinic visits only (GM-only); 2) cardiology clinic visits only (CARD-only); 3) general medicine and cardiology (MIXED) clinic visits; and 4) neither general medicine nor cardiology clinic visits (no-GM/CARD). We used the Cox proportional hazards model to evaluate 1-year survival, controlling for clinical and demographic factors. Consistency of our results was examined by performing identical analysis on a cohort of patients discharged from VHA hospitals between October 1, 1994, and September 30, 1995 (cohort 2, n = 10,141).


RESULTS
The overall 1-year mortality rate was 23% in the primary cohort. The unadjusted mortality rate was highest for patients in the no-GM/CARD follow up (29%) and lowest for patients in the MIXED group (19%). By use of the MIXED group as reference and adjusting for important clinical and demographic factors, the risk of death (risk ratio [95% CI]) was 1.12 (0.94-1.34) in the CARD-only group, 1.26 (1.15-1.38) in the GM-only group, and 1.48 (1.28-1.72) in the no-GM/CARD group. Cohort-2 results were consistent with cohort 1 for most covariates, and significant survival differences were again found between GM-only and the MIXED group (1.25 [1.14-1.37]).


CONCLUSIONS
We found an improved survival associated with cardiologist care and a mixture of general practitioner and cardiologist care compared with general practitioner care. The pattern of outpatient care may therefore be important for the survival of patients with CHF.
Indridason
Olafur S
OS
Department of Medicine, Division of Nephrology, Duke University Medical Center, Durham, NC, USA.
Coffman
Cynthia J
CJ
Oddone
Eugene Z
EZ
D000368:Aged; D002309:Cardiology / Q000592:standards* / Q000706:statistics & numerical data; D002983:Clinical Competence; D015331:Cohort Studies; D016208:Databases, Factual; D005194:Family Practice / Q000592:standards* / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006333:Heart Failure / Q000401:mortality* / Q000628:therapy*; D006787:Hospitals, Veterans / Q000592:standards; D006801:Humans; D008297:Male; D017063:Outcome Assessment, Health Care; D010044:Outpatient Clinics, Hospital / Q000592:standards*; D010351:Patient Discharge; D011379:Prognosis; D016016:Proportional Hazards Models; D015996:Survival Rate; D014481:United States / Q000453:epidemiology