Published online before print June 23, 2003, doi: 10.1161/01.CIR.0000080290.39027.48
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(Circulation. 2003;108:184.)
© 2003 American Heart Association, Inc.
Clinical Investigation and Reports |
Care and Outcomes of Patients Newly Hospitalized for Heart Failure in the Community Treated by Cardiologists Compared With Other Specialists
From the Heart & Stroke/Richard Lewar Centre of Excellence (P.J., P.P.L.); Division of Cardiology (P.J., P.P.L.), Toronto General Hospital, University Health Network; Institute for Clinical Evaluative Sciences (P.J., Y.G., P.C.A., D.S.L., J.V.T.); Department of Public Health Sciences (P.C.A., J.V.T.), University of Toronto; and Division of General Internal Medicine and the Clinical Epidemiology and Health Care Research Program (J.V.T.), Sunnybrook and Women’s College Health Sciences Centre, Toronto, Ontario, Canada.
Correspondence to Jack V. Tu, MD, PhD, Institute for Clinical Evaluative Sciences, G-106, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada. E-mail tu{at}ices.on.ca
Received February 10, 2003; revision received April 14, 2003; accepted April 16, 2003.
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Abstract |
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Background— It is not known whether subspecialty care by cardiologists improves outcomes in heart failure patients from the community over care by other physicians.
Methods and Results— Using administrative data, we monitored 38 702 consecutive patients with first-time hospitalization for heart failure in Ontario, Canada, between April 1994 and March 1996 and examined differences in processes of care and clinical outcomes between patients attended by physicians of different disciplines. We found that patients attended by cardiologists had lower 1-year risk-adjusted mortality than those attended by general internists, family practitioners, and other physicians (28.5% versus 31.7%, 34.9%, and 35.9%, respectively; all pairwise comparisons, P<0.001). The 1-year risk-adjusted composite outcome of death and readmission for heart failure was also lower for the cardiologists compared with family practitioners and other physicians but not general internists (54.7% versus 58.1%, 58.3%, and 55.4%; P<0.001, P<0.001, and P=0.39, respectively). Multivariable hierarchical modeling demonstrated a significant physician-level effect for both outcomes in favor of the cardiologists, particularly against non-general internists. Cardiologist care was associated with higher adjusted rates of invasive interventions and postdischarge prescriptions of heart failure medications.
Conclusions— In this population-based cohort, heart failure patients attended by cardiologists in hospital had lower risk of death as well as the composite risk of death or readmission than patients attended by noncardiologists. These data raise the need to identify specialty-driven differences in processes of care for heart failure patients, which may explain the observed disparity in clinical outcomes that presently favor cardiologist care.
Key Words: heart failure • prognosis • population • mortality • morbidity
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Introduction |
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Despite the dissemination of clinical guidelines1,2 on the treatment of heart failure, wide variations still exist in practice patterns between physicians of differing specialties who care for patients with this condition.3 Past observational studies have suggested that patients who were hospitalized for heart failure might receive better evidence-based care if attended by cardiologists compared with physicians of other disciplines.4,5 It remains unclear, however, whether these differences would result in improved clinical outcomes that would favor cardiologist-delivered care.4,6 Furthermore, if such specialty-related disparity in either care or outcome exists, it will be most visible among patients who are hospitalized for the initial heart failure episode, during which subspecialty care is expected to make the greatest impact.7 In this study, we conducted a population-based analysis to determine physician specialty-related differences in the care and outcome of unselected patients who were admitted for an initial episode of heart failure in Ontario, Canada, a province with a population of 11 million people. We hypothesized that differences would exist in selected processes of care of patients hospitalized for heart failure between physicians of differing specialties and that specialty care by cardiologists delivered in hospital would be associated with improved outcomes compared with care delivered by general internists, family practitioners, and physicians of other disciplines.
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Methods |
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Cohort Construction
Using data from the Canadian Institute for Health Information (CIHI),8 we constructed a cohort of consecutive patients who were hospitalized for the first time for heart failure in Ontario between April 1, 1994 and March 31, 1996.9 We identified all individuals (n=75 642) who were admitted with a primary diagnosis of congestive heart failure (International Classification of Diseases, 9th Revision, code 428). We excluded individuals who were younger than 20 years of age (n=273), those without a valid Ontario health card number (n=927), those admitted to chronic care facilities (n=713), those transferred from another acute care facility (n=1626), and non-Ontario residents (n=660). We also excluded cases where heart failure was coded as a hospital complication (n=493) and all cases in which it was not the first admission for heart failure in the time period of the study (n=23 268). Finally, we excluded all patients who had a diagnosis of heart failure coded during any hospital admission in the 5 years before this study (n=8980).
Indicators and Outcomes
We classified all admissions according to the medical specialty of the most responsible physician noted on the discharge records—cardiologist, general internist, family practitioner, or physician of other disciplines. The most responsible physician was defined as the single physician who provided the most days of in-hospital care. When the duration of care provided was equal among 2 or more physicians, the most responsible physician was the one who last cared for the patient. Physician specialties were assigned by the hospitals and reflected both the level of training and the type of services provided by the physicians.
Comorbidities were abstracted from the discharge abstracts of all hospitalizations within 5 years before the index admission using the Deyo adaptation10 of the Charlson comorbidity index.11 We captured the use of cardiac catheterization, percutaneous coronary interventions, and coronary artery bypass graft surgery within 30 days of index admission by linking our CIHI data to the Ontario Health Insurance Plan and the Ontario Same Day Surgery databases using encrypted health card numbers. We chose a 30-day cutoff to accommodate waiting times for these procedures. We also linked to the Ontario Drug Benefit database12 to capture the 90-day preadmission and 30-day postdischarge cardiac drug use for patients aged 
65 years. Readmissions attributable to heart failure after the index event were identified from the CIHI database. Deaths were captured by searching through both CIHI and the Ontario Registered Persons Database of Vital Status.
Quality of Administrative Databases
Fourteen acute care hospitals in Ontario with a minimum volume of 100 heart failure admissions per year participated in chart audits to validate the accuracy of our administrative databases for patients with heart failure. Trained abstractors, who were blinded to the original data, reviewed randomly selected charts of patients with first-time hospitalization for heart failure between April 1, 1997, and March 31, 1999. We applied the Framingham criteria13 and the Carlson heart failure score14 to ascertain the diagnosis of heart failure on admission. The diagnosis of heart failure was confirmed if 2 major or 1 major and 2 minor Framingham criteria were concurrently present or alternatively if the Carlson heart failure score exceeded 4 points. We also recorded the medical specialty of the discharging physician. The reabstracted patient and physician data were then compared with our original data to determine the reliability of our databases.
Statistical Analysis
Risk-adjusted outcome rates for mortality, readmission, procedure use, and postdischarge medication use were computed for patients treated by each physician specialty category. This was done by fitting multivariable regression models to adjust for patient-level characteristics that might confound our comparisons. Logistic regression was used to model 1-year mortality, the composite outcome of death or readmission at 1 year, procedure use, and postdischarge medication use. Poisson regression was used to model the number of readmissions within 1 year of discharge among survivors of the index admission. Only comorbidities with a prevalence of at least 1% in our cohort were considered for inclusion in our models.9 All covariates that had a significance level of P<0.20 by univariate analysis were then entered into the multivariable models. Backwards elimination was used to select variables until all remaining covariates were significant at the 
=0.05 level. The variables used in our case-mix adjustments included age, sex, history of myocardial infarction, peripheral vascular disease, cerebrovascular disease, dementia, chronic pulmonary disease, rheumatologic disease, peptic ulcer disease, liver disease, diabetes, hemiplegia or paraplegia, renal disease, malignancy, and AIDS. The statistical significance of differences in adjusted rates was determined using permutation tests.15 The c statistics16 in our logistic models showed adequate discriminative powers (0.68 to 0.79), and Hosmer-Lemeshow 
2 tests17 showed no lack of fit (P=0.27 to 0.94).
Risk-adjusted survival curves were computed using the corrected group prognosis method.18 Log likelihood tests, based on the Cox proportional hazards models from which the curves were derived, were used to test for the overall significance of a physician specialty effect on clinical outcomes. Model selections for our Cox regression were done using the same method as described above.
Our data had a natural hierarchical structure, with patients treated by physicians, who in turn practice within hospitals.19 To account for variables being measured at different levels of the hierarchy, multilevel logistic regression models were used to determine the relative odds for adverse outcomes between different physician specialties. The variables used for patient-level characteristics were identical to those used in the nonhierarchical models as described above. Physician specialty was used as the variable for physician-level characteristic, whereas hospital type/size was used as the variable for hospital-level characteristic. The hospitals were classified into the following types/sizes: teaching, large volume (100 heart failure admissions per year), medium volume (33 to 99 admissions per year), and low volume (<33 admissions per year). Such hierarchical modeling avoids the underestimation of the standard errors of the physician-level effect that are associated with traditional regression modeling.20 The models yielded odds ratios (ORs) that described the adjusted risks in adverse outcomes comparing care by other physician specialties against care by cardiologists. Multilevel analyses were implemented using HLM version 5.21 The remaining analyses were conducted using SAS 8.2 (SAS Institute Inc). The study was approved by the Research Ethics Board at the Sunnybrook & Women’s College Health Sciences Centre.
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Results |
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Cohort Characteristics
A total of 38 702 patients were hospitalized for heart failure for the first time during the study period. Of these, 14.2% were cared for by cardiologists, 35.0% by general internists, 41.0% by family practitioners, and 9.9% by other physicians (Table 1). Patients of cardiologists were younger and more likely to be male than patients of noncardiologists. Patients of cardiologists were more likely to have had a history of ischemic heart disease, atrial fibrillation, and prior cardiac surgery. Patients of cardiologists also had lower Charlson comorbidity scores than patients of noncardiologists. There was a higher preadmission use of cardiac medications for non-heart failure indications in the cardiologist group. Proportionally more cardiologist-managed patients were admitted to teaching hospitals, whereas more patients of noncardiologists were managed in community hospitals.
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Processes of Care
Table 2 shows that cardiologist care was associated with higher rates of invasive interventions than noncardiologist care. Patients attended by cardiologists had the highest adjusted rate of cardiac catheterization at 30 days compared with general internists, other physicians, and family practitioners (6.3% versus 2.7%, 1.8%, and 1.2%, respectively; all pairwise comparisons; P<0.001). Similar differences in favor of cardiologists were also noted in the adjusted rates for percutaneous coronary interventions (0.2% versus 0.1%, 0.1%, and 0.06%; P=0.01, 0.05, and 0.01, respectively). At 30 days, more patients cared for by cardiologists underwent bypass surgery than other physicians and family practitioners but not general internists (adjusted rates, 0.9% versus 0.5%, 0.3%, and 0.7%; P=0.02, P
0.001, and P=0.24).
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Among hospital survivors, significant between-specialty differences were seen in the 30-day postdischarge adjusted rates of heart failure medication use (Table 2). ACE inhibitor use was higher among the cardiologists than family practitioners or other physicians but not general internists (adjusted rates, 63.8% versus 58.1%, 56.3%, and 63.9%; P<0.001, P<0.001, and P=0.87). ß-Blocker use was highest among the cardiologists, followed by general internists, other physicians, and family practitioners (adjusted rates, 15.1% versus 11.0%, 8.7%, and 7.2%; all P<0.001).
Clinical Outcomes
The Figure and Table 3 showed that the risk-adjusted outcomes were highly disparate between patients cared for by different physician groups. The lowest in-hospital mortality rate was observed with the cardiologists, followed by general internists, family practitioners, and other physicians (risk-adjusted rates, 6.5% versus 8.9%, 10.4%, and 10.5%; all P<0.001). This specialty-related gradient in mortality was apparent within the first 72 hours after admission (1.7% versus 3.3%, 3.7%, and 3.8%; all P<0.001). The mortality benefit associated with cardiologist care was sustained at 1 year (28.5% versus 31.7%, 34.9%, and 35.9%; all P<0.001). The risk-adjusted number of heart failure readmissions per patient year among survivors of the index admission was similar between the physician groups at 1 month. At 1 year, the rate was slightly higher with the cardiologists than general internists and other physicians but not family practitioners (risk-adjusted number per patient-year, 0.76 versus 0.70, 0.70, and 0.73; P=0.004, 0.02, and 0.07). The composite outcome of death or readmission for heart failure at 1 month was lower among patients attended by cardiologists than general internists, family practitioners, and other physicians (risk-adjusted rates, 19.3% versus 21.9%, 23.2%, and 22.2%; all P<0.001), although by 1 year the advantage over the general internists had been lost.
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Table 4 showed that the mortality benefit associated with cardiologist care extended from the medium- to high-risk heart failure patients as predefined by age and the Charlson comorbidity score. In contrast, when only low-risk heart failure patients were considered, the 1-year mortality was similar between the physician groups.
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Table 5 summarized the physician-level effect observed on death and readmission as derived from the hierarchical models. Compared with cardiologists, the risk of in-hospital death increased in succession from general internists to other physicians to family practitioners (respective OR, 1.44, 1.78, and 1.80 versus cardiologists; all P<0.001). At 1 year, survival remained favorable for the cardiologists compared with other specialty groups (ORs, 1.16, 1.40, and 1.44; P=0.002, P<0.001, and P<0.001). When the composite outcome of death and readmission was considered, cardiologist care had a significantly lower 1-month risk than care by general internists, family practitioners, and other physicians (OR, 1.14, 1.16, and 1.21; P=0.02, 0.009, and 0.001). At 1 year, the risk reduction seen with the cardiologists was lost against the general internists but remained sustained compared with family practitioners and other physicians (OR, 1.04, 1.16, and 1.14; P=0.32, 0.001, and 0.01).
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Of the patients primarily attended by general internists and family practitioners, only 5.5% and 6.1%, respectively, received additional consultations from cardiologists. When these cases with cooperative care were excluded, the results did not differ significantly from our original analyses.
Reliability of Administrative Data
Our administrative data were verified to be reliable by chart audits. Of the 1346 heart failure hospitalizations identified by CIHI, 1292 (96%) met the Framingham criteria and 1211 (90%) met the Carlson criteria for heart failure by chart reabstraction. Among the 224 cases in which a cardiologist was identified by CIHI to be the most responsible physician, chart reabstraction found matching specialty of the discharging physician in 208 cases (93%). On the other hand, among the 857 cases in which the discharging physician was not a cardiologist on chart reabstraction, concordant classification of the most responsible physician by CIHI was observed in 841 cases (98%).
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Discussion |
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Our study showed that patients with first-time admissions for heart failure in the community attended by cardiologists in hospital had lower mortality risk as well as composite risk of death and readmission for heart failure than those attended by physicians of other disciplines. Cardiologist care was associated with more aggressive care and a higher postdischarge prescription use of heart failure medications.
No randomized study has been done that compares the clinical outcomes between cardiologist care and care delivered by other physician types in hospital for heart failure. In this context, our data sharply contrast with previous observational studies4,5,22 that did not demonstrate a significant specialty-related variation in mortality among patients hospitalized for heart failure. Such a discrepancy may be partly explained by differences between studies in patient selection, targeted processes of care, or duration of follow-up. Moreover, cohort studies7,23,24 that compared care between medical specialties in teaching hospitals might not detect the heterogeneity that would otherwise be observed in community practice. Presumably, generalists attending in teaching hospitals would adhere more closely to evidence-based care than generalists in the community, therefore lessening the chance of finding a difference that would be attributed to variation between physician groups. By including a wide range of both teaching and community hospitals in our study, we were able to detect a wider disparity in practice pattern that would be anticipated to influence clinical outcomes. Our study is therefore more consistent with existing evidence outside the field of heart failure, which has suggested that cardiology specialty care is superior to generalist care in managing acute cardiac illnesses such as myocardial infarction25 and unstable angina.26
The benefits seen with cardiologist care in our study were unlikely confounded by a selection bias with cardiologists "cherry-picking" low-risk patients. We showed that the mortality advantage in favor of cardiologist care was actually more evident among higher- than lower-risk subgroups of heart failure patients. Instead, the observed gradient in outcomes supports the hypothesis that subspecialty cardiologist care may be most beneficial in patients with complicated heart failure who carry the highest mortality risk. Similarly, the benefits of cardiologist care persisted after adjustment for hospital types and sizes, where resource differences may lead cardiologists from teaching hospitals to choose more invasive interventions than noncardiologists from community hospitals when caring for heart failure patients.
Our seemingly paradoxical finding of lower mortality but higher readmission among patients managed by cardiologists compared with other physicians may be the consequence of a survivor bias,27 because only subjects who survived the index hospitalization could be at risk for subsequent readmission. Surviving subjects of cardiologists who may not otherwise survive under other physicians’ care are at high risk of additional heart failure exacerbation, even when optimal care is delivered. Our finding may also reflect the subsequent lower threshold for hospital admission among patients treated by cardiologists.
Although it was not the focus of this study to identify specific process-outcome links that would support the superiority of cardiologist care, one source for the specialty-related differences in outcomes may be related to differences in specialty-driven processes of care.28 Cardiologists have reported practices that conform more closely with published guidelines for heart failure management than internists and family practitioners.3 The greater use of cardiac catheterization by cardiologists than noncardiologists29 is in accord with practice guidelines to identify reversible causes of heart failure and select patients in whom revascularization may improve survival. Our finding of a higher use of ACE inhibitors and ß-blockers among cardiologists’ patients concurred with other reports,4,5,29 even though our study took place in the mid 1990s, before the publication of large-scale clinical trials that demonstrated the benefits of ß-blockade in the heart failure population.
We could not exclude the possibility that differences in specialty and nonspecialty care received in the outpatient setting might be responsible for the improved 1-year prognosis among our cardiologists’ patients compared with patients of other physician groups. Disease management programs (eg, heart function clinics) that involve specialized follow-up by multidisciplinary teams have been shown to reduce hospitalizations in heart failure patients.30 Among heart failure patients managed in the outpatient setting, subspecialty care by cardiologists is associated with lower risks of death and hospitalization compared with general medicine and primary care.29,31 Yet we showed that the benefits associated with cardiologist care were most pronounced during the index hospitalization period. Thereafter, the relative benefits of cardiologist care compared with noncardiologist care diminished over time. This would suggest that the differences in long-term outcomes between patients attended by different physician groups in our study were more strongly associated with differences in care given in hospital than care given in the postdischarge period.
Economic constraint and limited access to cardiologists are both barriers to universal subspecialty care for all patients with heart failure. As such, our data should not be taken as a motion toward exclusive cardiologist care for all heart failure patients. Rather, this study raises the hypothesis that specific specialty-related differences in processes of care may partially explain the observed disparity in clinical outcomes. Although the magnitude of this disparity was only modest (as judged by the modest relative odds for adverse outcomes observed between cardiologists and noncardiologists), the impact of this disparity might still be significant because of the large number of heart failure patients hospitalized each year in the community and the proportionately large contribution of generalists compared with specialists in their care.
The reliability of coding of the CIHI database32 is comparable with other administrative databases from the United States33,34 used in heart failure research. Furthermore, we showed that the diagnosis of heart failure in our cohort could be confirmed in approximately 95% of the cases using the Framingham heart failure criteria. In more than 90% of the verifiable cases, the medical specialty of the most responsible physician on the discharge abstract also corresponded with that of the discharging physician recorded by chart reabstraction. The coding of the Ontario Drug Benefit database has been reported by others to be >99% accurate.12
Several limitations of our study should be noted. First, the use of administrative data necessarily restricted the collection of clinical variables that might provide better case-mix adjustment. In particular, undercoding of hypertension in the discharge abstracts limited accurate estimates of the prevalence of hypertension, a common cause of diastolic heart failure, in our population. Likewise, data on ejection fractions were not available. However, it is known that proportionally more patients of cardiologists have systolic dysfunction compared with generalists.7,23,29 Because survival is better with diastolic than systolic dysfunction,35 adjusting for ejection fraction may only magnify and not diminish the already disparate mortality observed between the physician groups. As in the case for all observational studies, a potential exists for unmeasured confounders that may bias our results. Second, the reliance on International Classification of Disease codes from discharge abstracts alone might result in undernumeration of heart failure cases that we sought to capture. Third, no information was available on the proportion of patients who had appropriate indication but did not receive a particular treatment. Finally, prescription use data were only available for patients aged 65 years or older, although this group accounted for 85% of our cohort.
In conclusion, our study showed that patients newly hospitalized for heart failure attended by cardiologists had lower mortality and lower composite risk of death and heart failure readmission compared with patients attended by physicians of other disciplines. These data raise the need to identify specific differences in processes of care between cardiologists and noncardiologists that may be responsible for the observed specialty-related disparity in heart failure outcomes.
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Acknowledgments |
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Dr Jong is supported by a Canadian Institutes of Health Research Fellowship. Dr Lee is supported by a Heart and Stroke Foundation of Canada/Canadian Institutes of Health Research Fellowship. Dr Tu is supported by a Canada Research Chair in Health Services Research. This study was supported by an operating grant to the Canadian Cardiovascular Outcomes Research Team (http://www.ccort.ca) from the Canadian Institutes of Health Research and the Heart & Stroke Foundation. The results and conclusions are strictly those of the authors, and should not be attributed to any of the sponsoring agencies.
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References |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
- Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol. 2001; 38: 2101–2113.
[Free Full Text]
- Liu P, Arnold M, Belenkie I, et al. The 2001 Canadian Cardiovascular Society consensus guideline update for the management and prevention of heart failure. Can J Cardiol. 2001; 17 (suppl E): 5E–25E.[Medline]
[Order article via Infotrieve]
- Edep ME, Shah NB, Tateo IM, et al. Differences between primary care physicians and cardiologists in management of congestive heart failure: relation to practice guidelines. J Am Coll Cardiol. 1997; 30: 518–526.[Abstract]
- Bellotti P, Badano LP, Acquarone N, et al. Specialty-related differences in the epidemiology, clinical profile, management and outcome of patients hospitalized for heart failure; the OSCUR study: Oucome dello Scompenso Cardiaco in relazione all’Utilizzo delle Risore. Eur Heart J. 2001; 22: 596–604.
[Abstract/Free Full Text]
- Philbin EF, Weil HF, Erb TA, et al. Cardiology or primary care for heart failure in the community setting: process of care and clinical outcomes. Chest. 1999; 116: 346–354.
[Abstract/Free Full Text]
- Srivatsa S, Amjadi HR. Generalist and cardiologist care for congestive heart failure. Ann Intern Med. 2000; 133: 481–482.
[Free Full Text]
- Auerbach AD, Hamel MB, Davis RB, et al. 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: 191–200.
[Abstract/Free Full Text]
- Discharge Abstract Database Data Quality Re-abstraction Study. Combined Findings for Fiscal Years 1999/2000 and 2000/2001. Ottawa, Ontario: Canadian Institute for Health Information; 2002.
- Jong P, Vowinckel E, Liu PP, et al. Prognosis and determinants of survival in patients newly hospitalized for heart failure: a population-based study. Arch Intern Med. 2002; 162: 1689–1694.
[Abstract/Free Full Text]
- Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992; 45: 613–619.[CrossRef][Medline]
[Order article via Infotrieve]
- Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987; 40: 373–383.[CrossRef][Medline]
[Order article via Infotrieve]
- Levy AR, O’Brien BJ, Sellors C, et al. Coding accuracy of administrative drug claims in the Ontario Drug Benefit database. Can J Clin Pharm. 2003; 10: 67–71.
- Ho KK, Anderson KM, Kannel WB, et al. Survival after the onset of congestive heart failure in Framingham Heart Study subjects. Circulation. 1993; 88: 107–115.
[Abstract/Free Full Text]
- Carlson KJ, Lee DC, Goroll AH, et al. An analysis of physicians’ reasons for prescribing long-term digitalis therapy in outpatients. J Chronic Dis. 1985; 38: 733–739.[CrossRef][Medline]
[Order article via Infotrieve]
- Good P. Permutation Tests. 2nd ed. New York: Springer-Verlag; 2000.
- Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology. 1982; 143: 29–36.
[Abstract/Free Full Text]
- Hosmer DW, Lemeshow S. Applied Logistic Regression. New York: Wiley; 1989.
- Ghali WA, Quan H, Brant R, et al. Comparison of 2 methods for calculating adjusted survival curves from proportional hazards models. JAMA. 2001; 286: 1494–1497.
[Abstract/Free Full Text]
- Snijders TAB, Boster RJ. Multilevel Analysis: An Introduction to Basic and Advanced Multilevel Modeling. London: Sage Publication; 1999.
- Greenfield S, Kaplan SH, Kahn R, et al. Profiling care provided by different groups of physicians: effects of patient case-mix (bias) and physician-level clustering on quality assessment results. Ann Intern Med. 2002; 136: 111–121.
[Abstract/Free Full Text]
- Bryk A, Raudenbush S, Congdon R. Hierarchical Linear and Nonlinear Modeling With the HLM/2L and HLM/3L Programs. Chicago, Ill: SPSS Inc; 1996.
- 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: 491–496.[CrossRef][Medline]
[Order article via Infotrieve]
- Harjai KJ, Boulos LM, Smart FW, et al. Effects of caregiver specialty on cost and clinical outcomes following hospitalization for heart failure. Am J Cardiol. 1998; 82: 82–85.[CrossRef][Medline]
[Order article via Infotrieve]
- Reis SE, Holubkov R, Edmundowicz D, et al. 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: 733–738.[Abstract]
- Ayanian JZ, Hauptman PJ, Guadagnoli E, et al. Knowledge and practices of generalist and specialist physicians regarding drug therapy for acute myocardial infarction. N Engl J Med. 1994; 331: 1136–1142.
[Abstract/Free Full Text]
- Schreiber TL, Elkhatib A, Grines CL, et al. Cardiologist versus internist management of patients with unstable angina: treatment patterns and outcomes. J Am Coll Cardiol. 1995; 26: 577–582.[Abstract]
- Sackett DL. Bias in analytic research. J Chronic Dis. 1979; 32: 51–63.[CrossRef][Medline]
[Order article via Infotrieve]
- Krumholz HM, Baker DW, Ashton CM, et al. Evaluating quality of care for patients with heart failure. Circulation. 2000; 101: E122–E140.[Medline]
[Order article via Infotrieve]
- Ansari M, Alexander M, Tutar A, et al. Cardiology participation improves outcomes in patients with new-onset heart failure in the outpatient setting. J Am Coll Cardiol. 2003; 41: 62–68.
[Abstract/Free Full Text]
- McAlister FA, Lawson FM, Teo KK, et al. A systematic review of randomized trials of disease management programs in heart failure. Am J Med. 2001; 110: 378–384.[CrossRef][Medline]
[Order article via Infotrieve]
- Indridason OS, Coffman CJ, Oddone EZ. Is specialty care associated with improved survival of patients with congestive heart failure? Am Heart J. 2003; 145: 300–309.[CrossRef][Medline]
[Order article via Infotrieve]
- Austin PC, Daly PA, Tu JV. A multicenter study of the coding accuracy of hospital discharge administrative data for patients admitted to cardiac care units in Ontario. Am Heart J. 2002; 144: 290–296.[CrossRef][Medline]
[Order article via Infotrieve]
- Goff DC, Pandey DK, Chan FA, et al. Congestive heart failure in the United States: is there more than meets the I(CD code)? The Corpus Christi Heart Project. Arch Intern Med. 2000; 160: 197–202.
[Abstract/Free Full Text]
- Fisher ES, Whaley FS, Krushat WM, et al. The accuracy of Medicare’s hospital claims data: progress has been made, but problems remain. Am J Public Health. 1992; 82: 243–248.
[Abstract/Free Full Text]
- Gaasch WH. Diagnosis and treatment of heart failure based on left ventricular systolic or diastolic dysfunction. JAMA. 1994; 271: 1276–1280.[Abstract]
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 M. Hudson, H. Richard, and L. Pilote Differences in outcomes of patients with congestive heart failure prescribed celecoxib, rofecoxib, or non-steroidal anti-inflammatory drugs: population based study BMJ, June 11, 2005; 330(7504): 1370. [Abstract] [Full Text] [PDF]
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 S J Leslie, S P McKee, E A Imray, and M A Denvir Management of chronic heart failure: perceived needs of general practitioners in light of the new general medical services contract Postgrad. Med. J., May 1, 2005; 81(955): 321 - 326. [Abstract] [Full Text] [PDF]
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 S. Bernatsky, M. Hudson, and S. Suissa Anti-rheumatic drug use and risk of hospitalization for congestive heart failure in rheumatoid arthritis Rheumatology, May 1, 2005; 44(5): 677 - 680. [Abstract] [Full Text] [PDF]
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 J. A. Ezekowitz, C. van Walraven, F. A. McAlister, P. W. Armstrong, and P. Kaul Impact of specialist follow-up in outpatients with congestive heart failure Can. Med. Assoc. J., January 18, 2005; 172(2): 189 - 194. [Abstract] [Full Text] [PDF]
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J. G. Ray, Y. Gong, K. Sykora, and J. V. Tu Statin Use and Survival Outcomes in Elderly Patients With Heart Failure Arch Intern Med, January 10, 2005; 165(1): 62 - 67. [Abstract] [Full Text] [PDF]
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 R. M. Califf, T. Ryan, P. Douglas, and P. J. Goldschmidt-Clermont A time of accelerated change in academic cardiovascular medicine: Implications for academic divisions of cardiology and their training programs J. Am. Coll. Cardiol., November 16, 2004; 44(10): 1957 - 1965. [Abstract] [Full Text] [PDF]
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F. Gustafsson and J. M. O. Arnold Heart failure clinics and outpatient management: review of the evidence and call for quality assurance Eur. Heart J., September 2, 2004; 25(18): 1596 - 1604. [Abstract] [Full Text] [PDF]
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 D. N. Juurlink, M. M. Mamdani, D. S. Lee, A. Kopp, P. C. Austin, A. Laupacis, and D. A. Redelmeier Rates of Hyperkalemia after Publication of the Randomized Aldactone Evaluation Study N. Engl. J. Med., August 5, 2004; 351(6): 543 - 551. [Abstract] [Full Text] [PDF]
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W. B. Fye Introduction: the origins and implications of a growing shortage of cardiologists J. Am. Coll. Cardiol., July 21, 2004; 44(2): 221 - 232. [Abstract] [Full Text] [PDF]
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J. Hirshfeld Jr and W. B. Fye Summary of Task Force recommendations to address the growing shortage of cardiologists J. Am. Coll. Cardiol., July 21, 2004; 44(2): 272 - 275. [Full Text] [PDF]
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S. R. Majumdar, F. A. McAlister, and C. D. Furberg From knowledge to practice in chronic cardiovascular disease: a long and winding road J. Am. Coll. Cardiol., May 19, 2004; 43(10): 1738 - 1742. [Abstract] [Full Text] [PDF]
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 D. T. Ko, M. Mamdani, and D. A. Alter Lipid-Lowering Therapy With Statins in High-Risk Elderly Patients: The Treatment-Risk Paradox JAMA, April 21, 2004; 291(15): 1864 - 1870. [Abstract] [Full Text] [PDF]
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 D. H. Kim and S. A. Hunt Heart Failure Management: Caregiver Versus Care Plan Circulation, July 15, 2003; 108(2): 129 - 131. [Full Text] [PDF]
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