Generalist and Cardiologist Care for Congestive Heart Failure

IN RESPONSE:

Dr. Nurhussein points out differences between patients cared for by cardiologists and those cared for by generalists and wonders whether use of angiotensin-converting enzyme (ACE) inhibitors affects patient survival. Similar proportions of patients in each category received ACE inhibitors at the time of discharge. However, models adjusting for use of ACE inhibitors at discharge did not change short-term (30-day) or longer-term mortality findings. It remains possible that differences in dosing of ACE inhibitors may have affected patient survival, but our data do not permit us to discern these differences directly.

Our Table 1 displays in-hospital mortality, whereas our Table 5 displays mortality at 30 days of follow-up; differences in the percentages calculated by Dr. Nurhussein and those presented are due to censoring of data at time points after discharge.

Dr. Nurhussein also wonders whether closer examination of patients who died in the hospital may suggest clues to optimal hospital care. Although an often-quoted measure, hospital mortality may be a less sensitive indicator of the quality of care than processes associated with improved outcome (such as appropriate use of ACE inhibitors) (1). The number of in-hospital deaths in our cohort is too small to allow meaningful analyses examining this particular question.

Srivatsa and Amjadi suggest that other patient outcomes may be important in describing care of patients with congestive heart failure. We agree that quality of life, symptoms, and functional status would be important additional outcomes, yet these are commonly absent from studies—including ours—comparing specialty and generalist care. In contrast to investigators of other studies, we had information on patient preferences for care; it is likely that care concordant with patient wishes has a profound impact on quality of life.

Our discussion did not intend to prove a short-term survival benefit associated with specialty care. Rather, we presented findings that might foster discussion about how to weigh higher costs of specialty care against an uncertain chance of a survival difference. Some readers may feel that, given the study's limitations, the only reasonable conclusion is that specialty care costs more. Others may interpret our findings as consistent with a growing literature and may be more willing to accept the possibility of survival differences. Regardless, simply saying “we do it better” does not serve our patients well. We hope that this paper reinforces the idea that generalists and cardiologists should work together to put in place systems of care that ensure utilization of appropriate, efficacious therapies for all eligible patients, regardless of site or caregiver.

• Copyright ©2004 by the American College of Physicians