Original Contribution heart failure only. Ahmed et al.4 compared cardiologists
alone, generalists alone, and combined care for 1,075 hospitalized heart failure cases. Combined care resulted in better processes of care and lower rates of readmission. Cost of care was not evaluated and only heart failure diagnosis was included. Philbin et al.,5
The American Heart Hospital Journal in another study
of 44,926 heart failure patients in New York, found that cardiologists and internists had similar LOS, charges, deaths, and readmissions and that family practice physicians had the lowest utilization profile. The extent of consultation was not reported. Auerbach et al.,6
in the
Study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT) of 1,298 hospitalized heart failure patients, reported that cardiologists’ patients incurred 43 % increased hospital cost compared with generalists’ patients, with a non-significant trend in adjusted mortality at one year favoring cardiologists’ care. In this study, 40 % of generalists’ patients had a cardiology consultation. Frances et al.,7
in a study of 161,558 elderly patients with
myocardial infarction, reported a 2 % mortality reduction at one year for patients admitted to a cardiologist. Utilization was not studied, nor were consultation patterns by non-cardiologists. Finally, a study of care patterns in acute myocardial infarction comparing cardiologists alone, generalists, and generalists with cardiology consultation revealed more appropriate care for cardiologists alone or in consultation with generalists when compared with generalists alone.8
From the current literature it is
reasonably clear that cardiologists alone or in consultation with generalists improve recommended care processes for heart failure and acute myocardial infarction. Mortality and cost patterns are inconsistent across studies. It is unclear from current studies if cardiologists should take the lead or should be a consultant to internists or hospitalists for the hospital care of cardiovascular diseases.
We sought to answer the following question for common cardiovascular diagnoses: does the cost and quality of inpatient care differ when a cardiologist is the principal attending physician compared with when an internist or hospitalist is the attending physician, with consultation by a cardiologist. A secondary question was whether procedure-based cardiovascular diagnoses would differ from non-procedure diagnoses with respect to the type of attending physician.
Methods Setting. The study was carried out in a large, urban, not-for-profit community teaching hospital in Florida.
82 Finding a Cardiologist’s Most Efficient and Effective Role
The study began October 1, 2000 and ended June 30, 2005. These dates corresponded to the beginning of availability of severity categories in the data set and the end of an academic year. The study population consisted of all patients admitted to a general internist, internal medicine hospitalist, or cardiologist as the attending physician, but excluded all patients on a teaching service. The hospital supported residencies in internal medicine, medicine-pediatrics, pediatrics, general surgery, orthopedics, obstetrics and gynecology, emergency medicine, and pathology. There were no internal medicine fellowships.
Physician Groups—Community General Internists (Internists). One hundred three internists admitted patients to the hospital and served as attending physician. Nearly all were in solo or small group practices. These physicians organized their own night and weekend coverage arrangements but usually admitted their own patients and performed daily hospital rounds. These physicians usually practiced at more than one hospital in the city.
Hospitalists. Sixty-six hospitalists admitted patients to the hospital. They were organized into seven groups of varying size and none were employed by the hospital. Most of the patients were from local physicians who were not engaged in hospital practice. Each hospitalist group arranged coverage for nights and weekends and none was present in hospital 24 hours per day.
Cardiologists. Seventy cardiologists, organized in groups of varying size from solo practitioners to large group practices of more than 20 members, served as attending physicians for patients in the study group. Call coverage was arranged individually for each group practice, although an individual cardiologist was assigned each day for emergency department calls.
Data Source and Collection. Trendstar clinical costing software (McKesson HBOC, San Francisco, CA) was used to collect information on all hospitalized patients. Trendstar uses an activity- based cost accounting system derived from the hospital’s ledger.9,10
Costs are then reported
including direct, indirect, fixed, and variable costs. Patients were grouped using All Patient Refined Diagnosis Related Groups (APRDRGs), severity level (1–4), and risk-of-mortality (ROM) level (1–4). APRDRG classification is assigned based on principal and secondary diagnosis, age, and procedure.11
assigned within the APRDRG.11
The severity level and ROM are All costs were assigned to
the single attending physician of each admission. Winter 2011
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