Differences among geriatricians, general internists, and cardiologists in the care of patients with heart failure: A cautionary tale of quality assessment

OBJECTIVES: To describe differences in the characteristics, processes of care, and resource utilization of patients with heart failure cared for by geriatricians, general internists, cardiologists, and combinations of physicians. DESIGN: A retrospective cohort study. SETTING: An urban academic medical center. PARTICIPANTS: A total of 439 outpatients with a billing diagnosis of heart failure or cardiomyopathy who were treated by geriatricians, general internists, cardiologists, and combinations of physicians. MEASUREMENTS: Demographic and clinical characteristics, medication use, diagnostic testing, hospitalizations, and inpatient and outpatient costs were measured. RESULTS: Compared with patients of cardiologists, patients cared for by geriatricians were older, more likely to have hypertension, diastolic dysfunction, and high comorbidity, and less likely to undergo echocardiography, cardiac catheterization, and electrocardiography. Use of angiotensin-converting enzyme inhibitors was similar among patients with reduced systolic function. Patients cared for by geriatricians had the same costs, rates of hospitalization, and likelihood of being symptomatic as patients of cardiologists. CONCLUSIONS: The processes of care for patients with heart failure seen solely by geriatricians differ from those for patients seen by other physicians, but the case-mix also varies. Assessment of left ventricular function by geriatricians probably needs to be increased. However, although they were older and had more comorbidity, patients of geriatricians had total costs and symptomatology similar to those of patients of cardiologists. Future work is needed to identify those patients most likely to benefit from treatment by geriatricians and to determine how care can be optimally coordinated among different types of physicians and health providers.