Improved outcomes with early collaborative care of ambulatory heart failure patients discharged from the emergency department

Douglas S. Lee, Thérèse A. Stukel, Peter C. Austin, David A. Alter, Michael J. Schull, John J. You, Alice Chong, David Henry, Jack V. Tu

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Abstract

Background: The type of outpatient physician care after an emergency department visit for heart failure may affect patients' outcomes. Methods and Results: Using the National Ambulatory Care Reporting System, we examined the care and outcomes of heart failure patients who visited and were discharged from the emergency department in Ontario, Canada (April 2004 to March 2007). Early collaborative care by a cardiologist and primary care (PC) physician within 30 days after discharge was compared with PC alone. Care for 10 599 patients (age, 74.9±11.9 years; 50.2% male) was provided by PC alone (n=6596), cardiologist alone (n=535), or concurrently by both cardiologist and PC (n=1478); 1990 did not visit a physician. Collaborative care patients were more likely to undergo assessment of left ventricular function (57.4% versus 28.7%), noninvasive stress testing (20.1% versus 7.8%), and cardiac catheterization (11.6% versus 2.7%) compared with PC. Drug prescriptions (patients a 65 years of age) demonstrated higher use of angiotensin-converting enzyme inhibitors (58.8% versus 54.6%), angiotensin receptor blockers (22.7% versus 18.1%), β-adrenoceptor antagonists (63.4% versus 48.0%), loop diuretics (84.2% versus 79.6%), metolazone (4.8% versus 3.4%), and spironolactone (19.8% versus 12.7%) within 100 days after emergency department discharge for collaborative care compared with PC. In a propensity-matched model, mortality was lower with PC compared with no physician visit (hazard ratio, 0.75; 95% confidence interval, 0.64 to 0.87; P<0.001). Collaborative care reduced mortality compared with PC (hazard ratio, 0.79; 95% confidence interval, 0.63 to 1.00; P=0.045). Sole cardiology care conferred a trend to increased mortality (hazard ratio, 1.41 versus collaborative care; 95% confidence interval, 0.98 to 2.03; P=0.067). Conclusions: Early collaborative heart failure care was associated with increased use of drug therapies and cardiovascular diagnostic tests and better outcomes compared with PC alone.

Original languageEnglish
Pages (from-to)1806-1814
Number of pages9
JournalCirculation
Volume122
Issue number18
DOIs
Publication statusPublished - 2 Nov 2010
Externally publishedYes

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Ambulatory Care
Hospital Emergency Service
Primary Health Care
Heart Failure
Confidence Intervals
Physicians
Mortality
Metolazone
Sodium Potassium Chloride Symporter Inhibitors
Drug Prescriptions
Spironolactone
Angiotensin Receptor Antagonists
Primary Care Physicians
Ontario
Cardiac Catheterization
Cardiology
Left Ventricular Function
Angiotensin-Converting Enzyme Inhibitors
Routine Diagnostic Tests
Adrenergic Receptors

Cite this

Lee, D. S., Stukel, T. A., Austin, P. C., Alter, D. A., Schull, M. J., You, J. J., ... Tu, J. V. (2010). Improved outcomes with early collaborative care of ambulatory heart failure patients discharged from the emergency department. Circulation, 122(18), 1806-1814. https://doi.org/10.1161/CIRCULATIONAHA.110.940262
Lee, Douglas S. ; Stukel, Thérèse A. ; Austin, Peter C. ; Alter, David A. ; Schull, Michael J. ; You, John J. ; Chong, Alice ; Henry, David ; Tu, Jack V. / Improved outcomes with early collaborative care of ambulatory heart failure patients discharged from the emergency department. In: Circulation. 2010 ; Vol. 122, No. 18. pp. 1806-1814.
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abstract = "Background: The type of outpatient physician care after an emergency department visit for heart failure may affect patients' outcomes. Methods and Results: Using the National Ambulatory Care Reporting System, we examined the care and outcomes of heart failure patients who visited and were discharged from the emergency department in Ontario, Canada (April 2004 to March 2007). Early collaborative care by a cardiologist and primary care (PC) physician within 30 days after discharge was compared with PC alone. Care for 10 599 patients (age, 74.9±11.9 years; 50.2{\%} male) was provided by PC alone (n=6596), cardiologist alone (n=535), or concurrently by both cardiologist and PC (n=1478); 1990 did not visit a physician. Collaborative care patients were more likely to undergo assessment of left ventricular function (57.4{\%} versus 28.7{\%}), noninvasive stress testing (20.1{\%} versus 7.8{\%}), and cardiac catheterization (11.6{\%} versus 2.7{\%}) compared with PC. Drug prescriptions (patients a 65 years of age) demonstrated higher use of angiotensin-converting enzyme inhibitors (58.8{\%} versus 54.6{\%}), angiotensin receptor blockers (22.7{\%} versus 18.1{\%}), β-adrenoceptor antagonists (63.4{\%} versus 48.0{\%}), loop diuretics (84.2{\%} versus 79.6{\%}), metolazone (4.8{\%} versus 3.4{\%}), and spironolactone (19.8{\%} versus 12.7{\%}) within 100 days after emergency department discharge for collaborative care compared with PC. In a propensity-matched model, mortality was lower with PC compared with no physician visit (hazard ratio, 0.75; 95{\%} confidence interval, 0.64 to 0.87; P<0.001). Collaborative care reduced mortality compared with PC (hazard ratio, 0.79; 95{\%} confidence interval, 0.63 to 1.00; P=0.045). Sole cardiology care conferred a trend to increased mortality (hazard ratio, 1.41 versus collaborative care; 95{\%} confidence interval, 0.98 to 2.03; P=0.067). Conclusions: Early collaborative heart failure care was associated with increased use of drug therapies and cardiovascular diagnostic tests and better outcomes compared with PC alone.",
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Improved outcomes with early collaborative care of ambulatory heart failure patients discharged from the emergency department. / Lee, Douglas S.; Stukel, Thérèse A.; Austin, Peter C.; Alter, David A.; Schull, Michael J.; You, John J.; Chong, Alice; Henry, David; Tu, Jack V.

In: Circulation, Vol. 122, No. 18, 02.11.2010, p. 1806-1814.

Research output: Contribution to journalArticleResearchpeer-review

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AU - Lee, Douglas S.

AU - Stukel, Thérèse A.

AU - Austin, Peter C.

AU - Alter, David A.

AU - Schull, Michael J.

AU - You, John J.

AU - Chong, Alice

AU - Henry, David

AU - Tu, Jack V.

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N2 - Background: The type of outpatient physician care after an emergency department visit for heart failure may affect patients' outcomes. Methods and Results: Using the National Ambulatory Care Reporting System, we examined the care and outcomes of heart failure patients who visited and were discharged from the emergency department in Ontario, Canada (April 2004 to March 2007). Early collaborative care by a cardiologist and primary care (PC) physician within 30 days after discharge was compared with PC alone. Care for 10 599 patients (age, 74.9±11.9 years; 50.2% male) was provided by PC alone (n=6596), cardiologist alone (n=535), or concurrently by both cardiologist and PC (n=1478); 1990 did not visit a physician. Collaborative care patients were more likely to undergo assessment of left ventricular function (57.4% versus 28.7%), noninvasive stress testing (20.1% versus 7.8%), and cardiac catheterization (11.6% versus 2.7%) compared with PC. Drug prescriptions (patients a 65 years of age) demonstrated higher use of angiotensin-converting enzyme inhibitors (58.8% versus 54.6%), angiotensin receptor blockers (22.7% versus 18.1%), β-adrenoceptor antagonists (63.4% versus 48.0%), loop diuretics (84.2% versus 79.6%), metolazone (4.8% versus 3.4%), and spironolactone (19.8% versus 12.7%) within 100 days after emergency department discharge for collaborative care compared with PC. In a propensity-matched model, mortality was lower with PC compared with no physician visit (hazard ratio, 0.75; 95% confidence interval, 0.64 to 0.87; P<0.001). Collaborative care reduced mortality compared with PC (hazard ratio, 0.79; 95% confidence interval, 0.63 to 1.00; P=0.045). Sole cardiology care conferred a trend to increased mortality (hazard ratio, 1.41 versus collaborative care; 95% confidence interval, 0.98 to 2.03; P=0.067). Conclusions: Early collaborative heart failure care was associated with increased use of drug therapies and cardiovascular diagnostic tests and better outcomes compared with PC alone.

AB - Background: The type of outpatient physician care after an emergency department visit for heart failure may affect patients' outcomes. Methods and Results: Using the National Ambulatory Care Reporting System, we examined the care and outcomes of heart failure patients who visited and were discharged from the emergency department in Ontario, Canada (April 2004 to March 2007). Early collaborative care by a cardiologist and primary care (PC) physician within 30 days after discharge was compared with PC alone. Care for 10 599 patients (age, 74.9±11.9 years; 50.2% male) was provided by PC alone (n=6596), cardiologist alone (n=535), or concurrently by both cardiologist and PC (n=1478); 1990 did not visit a physician. Collaborative care patients were more likely to undergo assessment of left ventricular function (57.4% versus 28.7%), noninvasive stress testing (20.1% versus 7.8%), and cardiac catheterization (11.6% versus 2.7%) compared with PC. Drug prescriptions (patients a 65 years of age) demonstrated higher use of angiotensin-converting enzyme inhibitors (58.8% versus 54.6%), angiotensin receptor blockers (22.7% versus 18.1%), β-adrenoceptor antagonists (63.4% versus 48.0%), loop diuretics (84.2% versus 79.6%), metolazone (4.8% versus 3.4%), and spironolactone (19.8% versus 12.7%) within 100 days after emergency department discharge for collaborative care compared with PC. In a propensity-matched model, mortality was lower with PC compared with no physician visit (hazard ratio, 0.75; 95% confidence interval, 0.64 to 0.87; P<0.001). Collaborative care reduced mortality compared with PC (hazard ratio, 0.79; 95% confidence interval, 0.63 to 1.00; P=0.045). Sole cardiology care conferred a trend to increased mortality (hazard ratio, 1.41 versus collaborative care; 95% confidence interval, 0.98 to 2.03; P=0.067). Conclusions: Early collaborative heart failure care was associated with increased use of drug therapies and cardiovascular diagnostic tests and better outcomes compared with PC alone.

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