Quality of Care for Decompensated Heart Failure: Comparable Performance between Academic Hospitalists and Non-hospitalists

Abstract

BACKGROUND: Hospitalists improve efficiency, but little information exists regarding whether they impact quality of care. OBJECTIVE:To determine hospitalists' effect on the quality of acute congestive heart failure care. DESIGN AND PARTICIPANTS:Using data from the Multicenter Hospitalist Study, we retrospectively evaluated quality of care in patients admitted with congestive heart failure who were assigned to hospitalists (n=120) or non-hospitalists (n=252) among six academic hospitals. MEASUREMENTS:Quality measures included the percentage of patients who had ejection fraction (EF) measurement, received appropriate medications [i.e., angiotensin-converting enzyme inhibitor (ACE-I) or betablockers] at discharge, measures of care coordination (e.g., follow-up within 30 days), testing for cardiac ischemia (e.g., cardiac catheterization), as well as hospital length of stay, cost, and combined 30-day readmissions and mortality.RESULTS: Compared to non-hospitalist physicians, hospitalists' patients had similar rates of EF measurement (85.3% vs. 87.5%; P=0.57), ACE-I (91.5% vs. 88.0%; P=0.52), or beta-blocker (46.9% vs. 42.1%; P=0.57) prescriptions. Multivariable adjustment did not change these findings. Hospitalists' patients had higher odds of 30-day follow-up (adjusted OR=1.83, 95% CI, 1.44 -2.93). There were no significant differences between the groups' frequency of cardiac testing, length of stay, costs, or risk for readmission or death by 30-days.CONCLUSION: Academic hospitalists and non-hospitalists provide similar quality of care for heart failure patients, although hospitalists are paying more attention to longitudinal care. Future efforts to improve quality of care in decompensated heart failure may require attention towards system-level factors.KEY WORDS: health services research; congestive heart failure; quality of care; hospital medicine; hospitalists.

Liability impact of the hospitalist model of care

“…Previous analyses of the costs associated with care by hospitalists, compared to care by other types of physicians, have not taken into account the decreased liability costs that are likely associated with care provided by hospitalists. 25,26 In conclusion, contrary to concerns that have been raised, we found that hospitalists face a lower rate of malpractice claims when compared to other internal medicine physicians and specialties. However, we did find that care discontinuities may be resulting in liability risk due to communication and handoff-related errors.…”

Outcomes of Patients With Acute Decompensated Heart Failure Managed by Cardiologists Versus Noncardiologists

“…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.…”

Influence of language barriers on outcomes of hospital care for general medicine inpatients

“…13,14 UCSF Moffitt-Long Hospital is a 400-bed urban academic medical center which provides services to the City and County of San Francisco, an ethnically and linguistically diverse area. UCSF employs staff language interpreters in Spanish, Chinese and Russian who travel to its many outpatient clinics, Comprehensive Cancer Center, Children's Hospital, as well as to Moffitt-Long Hospital upon request; phone interpretation is also available when in-person interpreters are not available, for off hours needs and for less common languages.…”

“…Patient mortality information was collected as part of the MHT using the National Death Index. 14 Language data were collected from a separate patientregistration database (STOR) at UCSF. Information on a patient's primary language is entered at the time each patient first registers at UCSF, whether for the index hospitalization or for prior clinic visits, and is based generally on patient self report.…”