Improved outcomes with early collaborative care of ambulatory heart failure patients discharged from the emergency department.
BACKGROUND
The type of outpatient physician care after an emergency department visit for heart failure may affect patients' outcomes.


RESULTS
Using the National Ambulatory Care Reporting System, we examined the care and outcomes of heart failure patients who visited and were discharged from the emergency department in Ontario, Canada (April 2004 to March 2007). Early collaborative care by a cardiologist and primary care (PC) physician within 30 days after discharge was compared with PC alone. Care for 10 599 patients (age, 74.9±11.9 years; 50.2% male) was provided by PC alone (n=6596), cardiologist alone (n=535), or concurrently by both cardiologist and PC (n=1478); 1990 did not visit a physician. Collaborative care patients were more likely to undergo assessment of left ventricular function (57.4% versus 28.7%), noninvasive stress testing (20.1% versus 7.8%), and cardiac catheterization (11.6% versus 2.7%) compared with PC. Drug prescriptions (patients ≥65 years of age) demonstrated higher use of angiotensin-converting enzyme inhibitors (58.8% versus 54.6%), angiotensin receptor blockers (22.7% versus 18.1%), β-adrenoceptor antagonists (63.4% versus 48.0%), loop diuretics (84.2% versus 79.6%), metolazone (4.8% versus 3.4%), and spironolactone (19.8% versus 12.7%) within 100 days after emergency department discharge for collaborative care compared with PC. In a propensity-matched model, mortality was lower with PC compared with no physician visit (hazard ratio, 0.75; 95% confidence interval, 0.64 to 0.87; P<0.001). Collaborative care reduced mortality compared with PC (hazard ratio, 0.79; 95% confidence interval, 0.63 to 1.00; P=0.045). Sole cardiology care conferred a trend to increased mortality (hazard ratio, 1.41 versus collaborative care; 95% confidence interval, 0.98 to 2.03; P=0.067).


CONCLUSIONS
Early collaborative heart failure care was associated with increased use of drug therapies and cardiovascular diagnostic tests and better outcomes compared with PC alone.
Lee
Douglas S
DS
Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON, M4N 3M5, Canada. dlee@ices.on.ca
Stukel
Thérèse A
TA
Austin
Peter C
PC
Alter
David A
DA
Schull
Michael J
MJ
You
John J
JJ
Chong
Alice
A
Henry
David
D
Tu
Jack V
JV
D000368:Aged; D000369:Aged, 80 and over; D047228:Angiotensin II Type 1 Receptor Blockers / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D002309:Cardiology; D004636:Emergency Service, Hospital / Q000639:trends*; D005260:Female; D006333:Heart Failure / Q000175:diagnosis* / Q000188:drug therapy / Q000401:mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000639:trends*; D010351:Patient Discharge / Q000639:trends*; D058007:Physicians, Primary Care; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors; D013038:Specialization; D015996:Survival Rate; D016896:Treatment Outcome
D047228:Angiotensin II Type 1 Receptor Blockers; D000806:Angiotensin-Converting Enzyme Inhibitors