The American Heart Hospital Journal
whether with or without a procedure. Overall LOS was also statistically significantly lower for cardiologists compared with internists, and also compared with hospitalists when a procedure was involved. The pattern of reduced Cost and LOS was consistent across lower and higher severity levels and was especially evident when the diagnosis included a cardiology procedure.
Table 4 summarizes the discharge status, hospital mortality, and 30-day readmission rates of the physician category for each diagnosis category. Mortality and 30-day readmission rates were analyzed using logistic regression analysis with age, gender, ethnicity, insurance, and physician category as independent variables. Severity was also an independent variable for 30-day readmission and risk of mortality was also an independent variable for mortality. Odds ratios with 95 % confidence intervals were produced. After adjustment for confounding variables, there were no statistically significant differences among the physician groups in hospital mortality or in 30-day readmissions.
Discussion
Our data suggest that, for the selected diagnosis groups of inpatients in our study, cardiologists working mostly alone as attending physician generally perform better economically than hospitalists or internists when acting as the principal attending physician of record.
Quality-of-care markers did not significantly differ among the physician categories after adjustment for patient characteristics. For cardiology procedure-related diagnoses, the Cost and LOS differences were especially evident. Our study expands the evidence that cardiologists can provide cost-effective inpatient care as the attending physician in cardiovascular diseases, when compared with an internist or hospitalist attending with consultation by a cardiologist. Our study is the first one that we are aware of to evaluate these attending physician models of care for several procedure and non-procedure cardiovascular diagnosis groups. Our finding that hospital cost and LOS were more nearly comparable among the three physician categories for non-procedure diagnoses and more divergent for procedure diagnoses makes sense. When a cardiovascular procedure is needed, the cardiologist is free to schedule and complete the procedure without waiting for a consultation request from another physician. When no procedure is involved, our study and most other studies have found only modest differences in cost or quality between generalists and cardiologists. Our study is similar to most other studies in finding little or no difference in readmission or death rates.5–7,12
We did not Winter 2011
Original Contribution
Table 4: Hospital Discharge Status, Hospital Mortality and 30-day Readmissions by Physician Category and Cardiovascular Diagnosis Category
CARDIOVASCULAR
DIAGNOSIS CATEGORY/ DISCHARGE/READMISSION
APRDRG
Without procedure Home
Nursing home Other Death
OR (CI)†
Readmission OR (CI)‡
APRDRG
With procedure Home
Nursing home Other Death
OR (CI)†
Readmission OR (CI)‡
INTERNIST HOSPITALIST CARDIOLOGIST n=1,819 n=4,290
n=769
93.0 5.2 0.7 1.2
92.0 4.5 1.9 1.7
3.2
95.1 1.3 1.8 1.8
0.5 (0.2–1.1) 0.7 (0.4–1.4) 1.0 4.1
4.4
0.9 (0.6–1.3) 0.7 (0.5–1.1) 1.0 n=1,339 n=3,283
93.5 4.8 0.8 0.9
91.3 5.8 1.2 1.7
3.2 n=3,613
95.4 2.1 1.1 1.4
0.5 (0.3–1.1) 0.8 (0.5–1.2) 1.0 2.9
3.3 0.9 (0.6–1.3) 1.0 (0.7–1.3) 1.0
*All numbers are unadjusted percentages except for OR (CI). †
insurance, and diagnosis category. ‡
Odds ratios (95 % confidence interval) where cardiologist is 1. Odds ratios are logistic regression adjusted for age, risk of mortality, ethnicity, gender,
Odds ratios (95 % confidence interval) where cardiologist is 1. Odds ratios are logistic regression adjusted for age, severity, ethnicity, gender, insurance, and diagnosis category.
APRDRG = All Patient Refined Diagnosis Related Group; CI = confidence interval; OR = odds ratio.
PHYSICIAN CATEGORY
evaluate processes of care or the use of guidelines by the physicians in our study. Our data and conclusions have limitations which we acknowledge. The data came from one hospital setting and may not be generalized to other settings. We used statistical procedures to adjust for multiple confounding variables that are of potential significance in making economic and quality-of-care comparisons. However, many other factors that we could not account for could have introduced a bias that would alternatively explain our results. Our study did not evaluate global healthcare costs.
It is possible that one group of physicians shifted more costs to the outpatient environment than other groups or performed more procedures than are necessary and thus increased overall costs rather than decreased them.We could not study this issue.
Finally, the optimal design to evaluate utilization and quality of care would be a randomized trial. n
Finding a Cardiologist’s Most Efficient and Effective Role 85
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