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Quality of Care for Patients Hospitalized With Heart Failure
Assessing the Impact of Hospitalists
Peter K. Lindenauer, MD, MSc;
Rona Chehabeddine, MPH;
Penelope Pekow, PhD;
Janice Fitzgerald, MS, RN;
Evan M. Benjamin, MD
Arch Intern Med. 2002;162:1251-1256.
ABSTRACT
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Background The quality of care provided to patients hospitalized for heart failure
has been shown to vary by physician, hospital, and region. Hospitalists appear
to reduce costs and length of stay, yet their impact on quality of care is
less certain.
Objective To compare quality of care and resource utilization among patients with
heart failure treated by hospitalists and nonhospitalist general internists.
Methods We reviewed the medical records of patients with a principal diagnosis
of heart failure between April 1, 1999, and March 30, 2000, at a 550-bed community-based
teaching hospital in Massachusetts. We evaluated quality of care by measuring
adherence to a set of commonly used process measures and compared resource
utilization using severity-adjusted length of stay and costs.
Results The analysis included 280 patients, accounting for 326 heart failure
admissions: 20 hospitalists cared for 137 (42%) cases, while 65 nonhospitalists
cared for 189 (58%). Of 137 hospitalist cases, 129 (94%) had new or prior
left ventricular ejection fraction testing results documented during the hospitalization
compared with 165 (87%) of 189 nonhospitalist cases (P
= .04). In cohorts of ideal candidates, performance rates for hospitalist
and nonhospitalist cases were similar for prescriptions of angiotensin-converting
enzyme inhibitors or angiotensin receptor blockers for patients with ejection
fractions lower than 40% (97% vs 96%; P>.99) and
warfarin for patients with atrial fibrillation (60% vs 55%; P = .64). Rates of comprehensive discharge counseling was similar in
the 2 groups. Multivariable modeling did not substantially alter these findings.
After adjusting for differences in severity, patients treated by hospitalists
had a shorter length of stay but similar overall costs when compared with
those treated by nonhospitalists.
Conclusion Compared with nonhospitalists, hospitalists were more likely to document
assessment of left ventricular function and their patients had a shorter length
of stay.
INTRODUCTION
HEART FAILURE affects some 5 million Americans1
and results in approximately 200 000 deaths each year. It is the leading
cause of hospital admission among Medicare beneficiaries, with annual costs
estimated to exceed $20 billion. Measured against standards developed from
clinical practice guidelines from the Agency for Healthcare Research and Quality,
the American Heart Association (AHA), and the Advisory Council to Improve
Outcomes Nationwide in Heart Failure,1-3
the quality of care for patients with heart failure has been shown to vary
by physician, hospital, and region.4-7
In light of these findings, improving the quality of care for patients hospitalized
with heart failure has been a high priority for the Health Care Financing
Administration's (HCFA's) Medicare program as well as the Joint Commission
on the Accreditation of Healthcare Organizations (JCAHO).8-9
Hospitalists are physicians whose primary professional focus is the general
medical care of hospitalized patients.10 In
settings ranging from large academic medical centers to small community-based
hospitals, hospitalists are playing an expanding role in providing care for
hospitalized children and adults.11-15
A recent workforce projection predicted that the field may ultimately grow
to as many as 10 000 to 30 000 and that hospitalists may eventually
come to dominate the inpatient care arena.16
As a result of the enormous financial pressures facing many American hospitals,
much of the early interest in hospitalists has focused on their potential
role in reducing length of stay and lowering costs.13, 17
There has been less attention paid to the effect of hospitalists on quality
of care, and evidence addressing this topic is limited.18
Because the growth of the hospitalist model carries major implications for
the care of patients with chronic illnesses such as heart failure, we sought
to determine whether the quality or costs of care for patients with heart
failure, as measured by a variety of process and outcome measures, differed
between hospitalists and their nonhospitalist generalist colleagues.
METHODS
DESIGN AND SETTING
We conducted a retrospective review of medical records at Baystate Medical
Center, a 570-bed community-based teaching hospital in Springfield, Mass,
that serves as the western campus of the Tufts University School of Medicine.
Three unique hospitalist groups (1 large academic faculty practice and 2 smaller
private group practices) provide care for patients admitted to the hospital's
general medical and cardiology units. As well as caring for patients from
the teaching clinics, faculty hospitalists are responsible for caring for
all patients with no identified primary care physician. In addition, numerous
small group practices continue to care for their own patients who require
hospitalization. Permission to carry out the study was obtained by the institutional
review board at Baystate Medical Center.
STUDY SAMPLE
We identified consecutive patients discharged with a principal diagnosis
of heart failure (International Classification of Diseases,
Ninth Revision, Clinical Modification codes 428-428.1, 428.9, 402.01,
402.11, 402.91, 404.01, 404.11, 404.91) for a 12-month period between April
1, 1991, and March 30, 2000. An experienced nurse abstractor reviewed the
medical records of potential cases. Patients were excluded from the study
if the diagnosis of heart failure could not be validated from a review of
the medical record. The coding of heart failure was considered correct if
the patient had symptoms, signs, or radiographic abnormalities consistent
with a diagnosis of heart failure. Patients were also excluded if the attending
of record was a cardiologist or other medical subspecialist, if they were
transferred to another acute care institution, or if they were designated
as receiving "comfort measures" only. Using a previously published definition,
physicians who spent at least 25% of their time caring for the hospitalized
patients of other physicians were considered hospitalists.19
SELECTION OF QUALITY INDICATORS
The measures of quality used in this study were derived from a set of
indicators developed by the JCAHO for use in their "Core Measures Initiative."8 The measures were produced by the JCAHO through a
consensus-based process that solicited in-depth input from hospitals, health
care purchasers, consumer groups, performance measurement systems, state medical
societies, and professional organizations. The 5 measures for heart failure
were selected for the ease with which they could be defined and measured,
their likelihood for improving health outcomes, and their reliability and
validity. Each indicator was evaluated in a restricted sample of patients
who were considered "ideal" candidates for the intervention (eg, for the smoking
cessation counseling indicator, only patients who were active smokers were
included in the denominator). The quality indicators for patients with heart
failure included the following:
- Measurement of left ventricular ejection fraction
before or during admission
- Use of angiotensin-converting enzyme (ACE) inhibitor
or angiotensin receptor blocker (ARB) at discharge for patients with left
ventricular ejection fraction lower than 40% and no contraindications to its
use
- Prescription of warfarin at the time of discharge
for eligible patients with atrial fibrillation and no contraindication to
its use
- Provision of smoking cessation advice or counseling
during hospitalization for patients with a history of smoking within the past
year
- Documentation regarding discharge medications,
daily weight monitoring, the importance of diet, activity level, and procedures
to follow if symptoms worsen.
SAMPLE SIZE
From previous studies,6, 20
we estimated ACE inhibitor or ARB use rates in ideal candidates to be approximately
70%. The 1-year period selected for this study was intended to provide enough
cases to have an 80% power to detect a 15% difference in ACE or ARB use rates
between hospitalist- and nonhospitalist-treated cases with an  of .05.
DATA COLLECTION
In addition to collecting information required to measure adherence
to the various quality measures, we recorded patient age, sex, ethnicity,
language spoken, whether the patient was a resident of a nursing home, whether
they had been transferred from another acute care facility, whether house
staff coverage was provided for the patient, and whether a cardiology consultation
was obtained during the hospitalization. A data collection tool was developed
and pilot tested to abstract relevant data from medical records using TELEform
(standard version 6.2; Cardiff Software Inc, Vista, Calif) and data were then
entered into a computerized database directly via facsimile. Abstraction errors
were reduced by providing detailed data definitions and by a reabstraction
of a random sample of medical records.
DATA ANALYSIS
Summary statistics for the overall sample were constructed using simple
frequencies and proportions for categorical data and means and SDs for continuous
variables. We assessed the association between potential confounders and both
the physician type and each quality of care indicator using  2
tests for independence. Factors that were found to be associated with both
physician type and a particular quality of care indicator were considered
confounders. Multiple logistic regression models were used to examine the
relationship between physician type and each of the dichotomous quality variables.
For each quality of care indicator, a model was constructed including the
physician type and identified confounders. The significance of each coefficient
in the model was evaluated, and nonsignificant variables (P .15) were eliminated from the model one at a time, starting with
the variable with the largest P value. Interaction
terms were also evaluated using similar criteria. When all statistically nonsignificant
terms were eliminated from the model, overall fit was assessed using the Hosmer-Lemeshow
Goodness of Fit Test. All analyses were carried out using SAS (version 8.0,
SAS Institute Inc, Cary, NC). Mantel-Haenszel–adjusted relative risks
for hospitalists relative to nonhospitalists for performance on quality of
care indicators were computed for the final models.
Cost and length of stay data were obtained directly from the hospital's
cost accounting system (Health Management Systems, El Segundo, Calif), and
figures represent actual costs and not charges. Comparisons of length of stay
and hospital costs between hospitalist and nonhospitalist cases were made
using the All Patient Refined–Diagnosis Related Groups (APR-DRG) patient
classification system (Version 15.0; 3M Corporation, Minneapolis, Minn) to
adjust for differences in severity, which is a risk adjustment method that
uses secondary diagnoses to assign patients to 1 of 4 levels of severity (mild,
moderate, major, and severe). Severity adjustment using the APR-DRG system
was limited to patients assigned to APR-DRG 127 (heart failure and shock).
Owing to the nonnormal distributions of length of stay and cost per case,
we used Kruskal-Wallis analysis of variance (adjusting for severity) to evaluate
differences between hospitalist and nonhospitalist cases.
RESULTS
PATIENT CHARACTERISTICS
The analysis included 282 patients, accounting for 326 heart failure
admissions; 20 hospitalists cared for 137 cases, while 65 nonhospitalists
cared for the remaining 189. Each hospitalist cared for a median of 5 heart
failure cases, while each nonhospitalist cared for a median of 2 cases (P<.001). Regarding the patients in this study, the mean
age was 74 years, 57% were women, most (62%) were white, English was the most
(91%) common language spoken at home, 13% were residents of nursing homes,
and 2% had been transferred from another acute care facility. Overall, the
average length of stay was 5 days and the in-hospital mortality rate was 5%.
Hospitalists, compared with their nonhospitalist colleagues (Table 1), cared for a larger proportion
of male patients (50% vs 37%; P = .02), and their
cases were more likely to receive house staff coverage (61% vs 29%; P<.001). Patient characteristics including age, race,
language spoken at home, whether the patient had been transferred from another
acute care facility, whether the patient was a resident of a nursing home,
and rates of cardiology consultation were similar in the 2 groups.
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Table 1. Characteristics of Study Patients by Physician Group
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QUALITY AND OUTCOME MEASURES
Of hospitalist cases, 94% had the results of new or prior left ventricular
function testing documented during the hospitalization compared with 87% of
nonhospitalist cases (P = .04) (Table 2). Among ideal candidates, performance rates for ACE inhibitor
or ARB use for patients with ejection fractions below 40% and warfarin prescription
at the time of discharge for ideal patients with atrial fibrillation were
similar in the 2 physician groups. Both physician groups performed poorly
with respect to smoking cessation. Rates of counseling at the time of discharge
regarding medication use, crisis management, diet, and weight monitoring varied,
but levels were similar for physician groups for each type of counseling.
The mortality rate was 5.8% for hospitalist-treated cases and 4.8% for nonhospitalist-treated
cases (P = .66). Fourteen patients (10%) cared for
by hospitalists were readmitted within 30 days of discharge compared with
26 (14%) of nonhospitalist-treated cases (P = .31).
Overall, one half of the patients cared for by hospitalists were discharged
within 3 days of admission, whereas half of the nonhospitalist cases were
still hospitalized on day 4. The median cost per case for patients cared for
by hospitalists was $3859 compared with $3932 for those cared for by nonhospitalist
generalists.
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Table 2. Performance on Quality Indicators and Outcomes by Physician
Group*
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IDENTIFICATION AND ADJUSTMENT FOR CONFOUNDING
Age, sex, race, nursing home residency, transfer status, house staff
coverage, and cardiology consultation were each associated with specific quality
of care indicators (data not shown). Adjusting for the confounding effects
of sex on the assessment or documentation of left ventricular function had
minimal effect on the overall point estimate but did increase the size of
the 95% confidence interval (Table 3).
Moreover, this process did not reveal any significant differences in performance
on other quality of care indicators between hospitalists and nonhospitalists
(Table 3).
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Table 3. Adjusted Associations Between Hospitalists and Quality Measures*
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SEVERITY-ADJUSTED OUTCOMES
Of the 326 study patients, 292 (90%) were assigned to APR-DRG 127 and
included in this analysis. Using the APR-DRG method of severity adjustment,
most (87%) of the cases was classified as either moderate or major severity.
Patients treated by hospitalists had an overall higher level of severity (Table 4), with 45% being classified as
major or severe compared with 29% for nonhospitalists. After adjusting for
this difference in severity, cases managed by hospitalists had a shorter length
of stay than those managed by nonhospitalists (P
= .03). This effect was most pronounced among the 88 patients in the major
severity category, wherein cases managed by hospitalists had a median length
of stay that was 2 days shorter than those managed by nonhospitalist generalists.
Although costs varied across each severity stratum, there were no overall
significant differences between the 2 groups (Table 4).
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Table 4. Severity-Adjusted Length of Stay and Costs for Patients With
Congestive Heart Failure Treated by Hospitalists and Nonhospitalists*
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COMMENT
As one of the leading indications for hospitalization nationwide, the
care of patients with heart failure has been the subject of a great deal of
attention by both governmental and professional organizations. Well-documented
variations in practice6, 21 have
led to a proliferation of clinical practice guidelines and quality improvement
initiatives aimed at improving quality of care while reducing costs. Coinciding
with these efforts, the growth of the hospitalist model has dramatically altered
the landscape of inpatient care for patients with chronic medical conditions,
such as heart failure, and may have important implications for those interested
in addressing quality of care.
The present study was designed to compare the quality and resource utilization
patterns for patients with congestive heart failure between those who were
cared for by hospitalists and those cared for by nonhospitalist general internists.
Unlike prior studies of hospitalists, in addition to comparing costs and length
of stay, we attempted to measure quality of care by focusing on a series of
evidence-based process measures that are believed to result in improved health
outcomes. After adjusting for the confounding effects of age, sex, and house
staff coverage, we found that hospitalists were somewhat more likely to assess
or document left ventricular function, while the use of ACE inhibitors or
ARBs, use of warfarin for patients with atrial fibrillation, and comprehensive
patient counseling at the time of discharge were similar. Although assessment
of left ventricular function and use of ACE inhibitors and ARBs were generally
high, like others6 we noted important opportunities
to improve practices surrounding warfarin use in eligible patients and to
improve patient education and counseling. We found small but clinically significant
differences in length of stay between hospitalists and nonhospitalist physicians
that persisted even after adjusting for differences in severity of illness.
A number of previous studies have examined the quality and outcomes
of care for patients hospitalized for treatment of heart failure using similar
process measures.4-7,22
These studies have demonstrated differences in the performance of individual
states, of hospitals within and across states, and of generalist and specialist
physicians. In addition, several studies have compared outcomes between hospitalist
and nonhospitalist physicians, although none has focused on a single condition
such as congestive heart failure or has attempted to measure quality of care
using widely accepted process measures. Wachter et al17
demonstrated reductions in length of stay and costs on a managed care service
that was staffed by hospitalist attendings. In that study, quality of care
was assessed using a health status questionnaire coupled with readmission
rates and mortality. While these measures provide valuable information, they
are often insensitive to important differences in quality and do not offer
insight into how outcomes may be affected by specific physician practice.
In similar fashion, Meltzer et al23 compared
the outcomes at an academic medical center and found that hospitalists had
lower lengths of stay, costs, and mortality compared with their nonhospitalist
counterparts. We are not familiar with any previous studies that have examined
differences in the quality of care between hospitalists and their generalist
colleagues focusing on evidence-based process measures. Advocates argue that
the evaluation of process measures provides information that can more readily
be translated into changes in practice that can improve patient outcomes.
In other words, for those interested in improving quality of care, process
measures are more directly "actionable" than outcome measures.
There are several significant limitations to this study. First, because
the study was carried out at a single institution, it is difficult to know
how well the small differences we observed in quality of care and length of
stay can be considered to be indicative of hospitalist practice generally.
However, despite the study's single hospital design, we included a heterogeneous
array of hospitalists practicing in 3 distinct physician groups: 1 academic
faculty practice and 2 private group practices. Second, we used a previously
described definition of a hospitalist as a physician who spends 25% or more
of his or her time caring for the hospitalized patients of other physicians.
As a result, the physicians that we categorized as hospitalists demonstrated
significant variation in the amount of time they spent in the hospitalist
role from 25% for physicians in the academic faculty practice to 100% in the
private group practices. If physician performance is directly related to the
proportion of time spent in the hospitalist role, then our study may have
been less likely to demonstrate differences in quality than if we had only
included full-time hospitalists. On the other hand, because the hospitalist
physicians in our study were representative of the diversity of hospitalist
practices nationwide,24 our findings may be
more generalizable than studies focused on only academic or private practice
models. A further limitation of the study relates to the selection of an appropriate
comparison group of physicians. Because hospitalists care for more than half
of all medical admissions at our institution, the primary care physicians
who continue to provide inpatient care may be better or worse than primary
care physicians elsewhere. Also, our institution has developed and uses a
practice guideline and accompanying order set for exacerbations of heart failure.
To the extent that these quality improvement interventions reduce variation
in practice, we are less likely to note differences between the 2 physician
groups.
Because of the study's retrospective design, it is difficult to know
whether performance rates on measures related to counseling and education
were due to documentation problems, implementation problems, or both. Moreover,
simply carrying out and documenting such measures as smoking cessation counseling
does not ensure that the counseling was done well. In addition, some of the
quality measures we chose may be less reflective of individual physician practice
and more indicative of institutional or nursing practice. This may explain
why we observed very little difference in rates of patient counseling at the
time of discharge between the 2 groups. Nevertheless, the JCAHO and the HCFA
have chosen to incorporate these measures into ongoing national quality improvement
initiatives.
We used the APR-DRG system for severity adjustment. This system uses
diagnosis codes to measure comorbid conditions and extent of disease.25 The APR-DRG results may be biased by random or systematic
errors in coding. In addition, the APR-DRG system does not incorporate physiologic
measures (eg, actual ejection fraction and blood pressure) to determine severity.
Unmeasured severity of illness may account for some of the differences between
the hospitalist- and nonhospitalist-treated cases of heart failure. Nevertheless,
APR-DRG is a widely used severity adjustment method that was associated with
both hospital lengths of stay and costs at our own institution.
In conclusion, while demonstrating lower length of stay, hospitalists
were somewhat more likely than nonhospitalist generalists to assess or document
the results of left ventricular testing while caring for patients hospitalized
with heart failure. Further studies should be carried out to better evaluate
the impact of hospitalists on quality of care for patients with heart failure
and other conditions that necessitate inpatient treatment.
AUTHOR INFORMATION
Accepted for publication October 15, 2001.
This study was presented at the annual meeting of the National Association
of Inpatient Physicians, Atlanta Ga, March 28, 2001.
Corresponding author: Peter K. Lindenauer, MD, MSc, Division of Healthcare
Quality, Baystate Medical Center, 759 Chestnut St P-5928, Springfield, MA
01199 (e-mail: Peter.Lindenauer{at}bhs.org).
From the Division of Healthcare Quality, Baystate Medical Center, Springfield,
Mass (Drs Lindenauer, Pekow, and Benjamin and Ms Fitzgerald), the Department
of Epidemiology and Biostatistics, University of Massachusetts, Amherst (Ms
Chehabeddine and Dr Pekow), and the Department of Medicine, Tufts University
School of Medicine, Boston, Mass (Drs Lindenauer and Benjamin).
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