Generalists Need Education on HF Treatment

February 07, 2012

February 7, 2012 (Toronto, Ontario)— Canadian researchers say they have, for the first time, been able to pinpoint why outcomes in heart-failure patients seem to differ depending upon the type of physician who administers care [1]. Dr Nicole K Boom (Institute for Clinical Evaluative Sciences, Toronto, ON) and colleagues found that HF patients treated by cardiologists fared better than those who were seen by family doctors or internists, but they caution that the reasons are "multifactorial and complex" in their paper in the February 2012 issue of the American Heart Journal.

Senior author Dr Jack V Tu (Institute for Clinical Evaluative Sciences) explained that cardiologists "tend to be more aggressive in their management of HF": for example, they were more likely to prescribe certain medications and order echocardiograms and angiograms than other physician specialties. But family doctors treated older patients more often, some of whom had "do-not-resuscitate" (DNR) orders; when DNRs were excluded, the differences in outcomes between the specialties were "significantly attenuated," he notes.

Tu told heartwire that as there are not enough cardiologists to treat all HF patients in Ontario, it is imperative that family doctors and others are educated as to the best practice in HF. Currently, about 20% of HF sufferers see a cardiologist, 30% an internist, and the remaining half are treated by family doctors.

Family doctors will be dealing with the vast majority of HF patients, so if we can understand how they can improve their care, that could improve patient outcomes.

"This is very useful information that we can use to target family doctors, who have historically gotten less attention in terms of professional education compared with specialists. We are not trying to say family doctors are bad; rather, they are the ones who--for the foreseeable future--will be dealing with the vast majority of HF patients, so if we can understand how they can improve their care, potentially that could improve patient outcomes."

Generalists Good on ACE-Inhibitor/ARB Use But Not Beta Blockers

Boom and colleagues examined physician-specialty–related differences in processes of care and clinical outcomes for 7634 patients newly hospitalized for HF in Ontario who were included in the EFFECT study between April 2004 and March 2005. Patients were categorized according to whether they received care from a cardiologist or generalist (eg, internist or family doctor) or generalist care with cardiology consultation.

Patients treated by generalists alone had a higher risk of 30-day mortality (odds ratio 1.50) and one-year mortality (OR 1.29), as well as a higher risk of a one-year composite outcome of death and hospital readmission, compared with those treated by cardiologists. But if patients with DNR orders were excluded, these differences were significantly reduced.

Those who had a cardiologist involved in their care were more likely to undergo diagnostic procedures and had higher rates of beta-blocker use (79.4% of those treated by a cardiologist took beta blockers compared with 67.3% of those seen by generalists alone).

The latter finding suggests that "a greater proportion of generalist physicians continue to be hesitant to initiate beta blockers in patients with HF, possibly because they are less aware of the clinical evidence to support this practice and/or have greater concerns about initiating this therapy in an older patient population with more comorbidities," say Boom et al.

There was no such uncertainty when it came to prescribing ACE inhibitors or angiotensin-receptor blockers (ARBs) to HF patients, however, "which suggests that this important aspect of HF has penetrated well among all types of physicians," they add.

"Most of the HF continuing education tends to be specialist driven," Tu observes, "but the ironic thing is, they are the most aware and probably need it less than the family doctor, who has to deal with HF and also has to deal with so many other things."

He added that these new findings will be shared with other groups trying to improve HF outcomes in Ontario and that the Canadian Cardiovascular Society has an ongoing knowledge-translation program aimed at trying to improve HF care.

The authors report that they have no relevant conflicts of interest.

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