Shared care helps reduce mortality in patients with heart failure
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《英国医生杂志》
Patients with newly diagnosed congestive heart failure who were followed up by both specialists and family doctors had lower one year mortality than those who saw only family doctors or had no specific cardiovascular follow up care, a Canadian study has found.
Of a total of 3136 patients discharged from 128 acute care hospitals in Alberta between April 1998 and July 2000 (median age 76 years; 50% men), 1062 (34%) received no follow up visits for cardiovascular care. Of the remainder, 738 (24%) were seen by a family doctor alone, 29 (1%) by a specialist (cardiologist or general internist) alone, and 1307 (42%) by a specialist and a family doctor (CMAJ 2005;172:189-94).
Compared with patients who received no follow up cardiovascular care, patients who regularly saw at least one doctor had fewer visits to the emergency department within a year (38% versus 80%) and fewer admissions to hospital (13% versus 94%), and their adjusted one year mortality was lower (22% versus 37%) (all P<0.001).
Patients cared for exclusively by family doctors had fewer visits to outpatient clinics than patients who received care from a specialist as well as a family doctor (medians nine and 17 visits in the first year, respectively). Fewer patients cared for only by family doctors presented to the emergency department than patients who also saw a specialist (24% versus 45% in the first year), and fewer were readmitted for cardiovascular care (7% versus 16%) (all P<0.001). However, adjusted one year mortality was lower among patients who received combined care (17% versus 28%; P<0.001), despite a higher burden of comorbidities.
In a multivariate model in which comorbidities were adjusted for (and in which patients with no cardiovascular follow up visits were the reference category), one year mortality was lower among patients who received follow up care by a family doctor alone (odds ratio 0.66 (95% confidence interval 0.53 to 0.82) and among patients who were followed up by both a family doctor and a specialist (odds ratio 0.34 (0.28 to 0.42)). And in a proportional hazards model with time dependent covariates and adjustments for frequency of follow up visits, the risk of mortality from all causes decreased significantly with each visit to a specialist (hazard ratio 0.98 (0.97 to 0.99), compared with care just from a family doctor.
All patients were followed from the date of their discharge from the hospital where the initial diagnosis was made until they died, or until 31 March 2001, whichever came first. Of the 236 specialists who submitted claims for cardiovascular diagnoses to Alberta抯 ambulatory care and physician claims database the during the study period, 202 worked in urban areas and 34 in rural areas.
The authors conclude that measures to improve timely and appropriate access to care from specialists are needed and that patients with new onset congestive heart failure are at particular risk of an early adverse outcome if they do not receive appropriate care.
In an accompanying commentary John Cleland, professor of cardiology at the University of Hull, says the study has important implications, but he does criticise its methods. For example, he says, "It is unfortunate that the authors confined their interest mainly to cardiovascular follow-up and admissions and paid little attention to the impact of all health care contacts."(Quebec David Spurgeon)
Of a total of 3136 patients discharged from 128 acute care hospitals in Alberta between April 1998 and July 2000 (median age 76 years; 50% men), 1062 (34%) received no follow up visits for cardiovascular care. Of the remainder, 738 (24%) were seen by a family doctor alone, 29 (1%) by a specialist (cardiologist or general internist) alone, and 1307 (42%) by a specialist and a family doctor (CMAJ 2005;172:189-94).
Compared with patients who received no follow up cardiovascular care, patients who regularly saw at least one doctor had fewer visits to the emergency department within a year (38% versus 80%) and fewer admissions to hospital (13% versus 94%), and their adjusted one year mortality was lower (22% versus 37%) (all P<0.001).
Patients cared for exclusively by family doctors had fewer visits to outpatient clinics than patients who received care from a specialist as well as a family doctor (medians nine and 17 visits in the first year, respectively). Fewer patients cared for only by family doctors presented to the emergency department than patients who also saw a specialist (24% versus 45% in the first year), and fewer were readmitted for cardiovascular care (7% versus 16%) (all P<0.001). However, adjusted one year mortality was lower among patients who received combined care (17% versus 28%; P<0.001), despite a higher burden of comorbidities.
In a multivariate model in which comorbidities were adjusted for (and in which patients with no cardiovascular follow up visits were the reference category), one year mortality was lower among patients who received follow up care by a family doctor alone (odds ratio 0.66 (95% confidence interval 0.53 to 0.82) and among patients who were followed up by both a family doctor and a specialist (odds ratio 0.34 (0.28 to 0.42)). And in a proportional hazards model with time dependent covariates and adjustments for frequency of follow up visits, the risk of mortality from all causes decreased significantly with each visit to a specialist (hazard ratio 0.98 (0.97 to 0.99), compared with care just from a family doctor.
All patients were followed from the date of their discharge from the hospital where the initial diagnosis was made until they died, or until 31 March 2001, whichever came first. Of the 236 specialists who submitted claims for cardiovascular diagnoses to Alberta抯 ambulatory care and physician claims database the during the study period, 202 worked in urban areas and 34 in rural areas.
The authors conclude that measures to improve timely and appropriate access to care from specialists are needed and that patients with new onset congestive heart failure are at particular risk of an early adverse outcome if they do not receive appropriate care.
In an accompanying commentary John Cleland, professor of cardiology at the University of Hull, says the study has important implications, but he does criticise its methods. For example, he says, "It is unfortunate that the authors confined their interest mainly to cardiovascular follow-up and admissions and paid little attention to the impact of all health care contacts."(Quebec David Spurgeon)