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Admit to where?

Heart failure care can be improved by reducing variation between medicine and cardiology.

For patients hospitalized with heart failure, receiving specialist care is associated with lower risk of short-term readmissions and mortality.

Yet not all heart failure inpatients are admitted to or seen by a cardiologist, studies show. For example, an examination of heart failure admissions at a large hospital over a one-year period found that 60% of patients were admitted to cardiology services while 40% were admitted to general medicine services.

Patients admitted to cardiology had more thorough discharge summaries, were more likely to leave with scheduled follow-up appointments, and had lower 30-day readmission rates compared with general medicine patients, according to results published in the May 1, 2018, American Journal of Cardiology.

Other studies have identified racial disparities in the receipt of subspecialty care, which may contribute to widely documented inequities in heart failure outcomes. Black and Latino patients were less likely than White patients to be admitted to cardiology services, according to a study of 10 years of admissions at one academic center, published in the November 2019 Circulation: Heart Failure. Subspecialty care was again associated with lower readmission risk in that study.

However, sending every patient to cardiology would be neither feasible nor effective as a means of improving heart failure outcomes and addressing racial disparities, experts said. They offered their advice on how hospitalists can collaborate with other clinicians to optimize triage and care.

“Hospitalists are used to thinking about care holistically, while cardiologists are focused on the long-term management of cardiac problems specifically,” said Alpesh Amin, MD, MBA, MACP, professor of medicine and director of the hospitalist program at the University of California, Irvine (UCI), School of Medicine in Irvine, Calif. “The question should really be how can we leverage the expertise of these and other specialties to accomplish the greater good for these patients.”

Factors in admission decisions

Admission decisions may not always be straightforward when patients present to the ED with symptoms suggestive of heart failure, especially if they have not been previously diagnosed with or admitted for heart failure, said cardiologist and ACP Member Parag Goyal, MD, MSc, assistant professor of medicine at Weill Cornell Medicine in New York and senior investigator of the American Journal of Cardiology paper.

“There are a host of factors that play a role in admission decisions, including medical factors—such as severity of illness and presence of high-risk features, like arrhythmias—and resource or bed availability on the cardiology service,” he said. Other considerations might include whether or not the hospital has a cardiac ICU or adequate staffing of its cardiology consultation service.

Initial decision making about admission varies widely across hospitals, said Stephen Greene, MD, a cardiologist and assistant professor of medicine at Duke Medical Center in Durham, N.C. At some hospitals, ED physicians have full admitting privileges and the authority to admit patients to different services within the hospital, including directly to cardiology. At others, cardiology must first accept a patient to their service after discussions with the ED.

Brigham and Women's Hospital recently changed its policy to allow ED clinicians to admit patients directly to cardiology without calling for a consult first, said hospitalist and chief resident Evan Shannon, MD. Prior to that change, the ED physician first consulted with a hospitalist or a cardiologist to confirm admission to the appropriate service.

Dr. Goyal's study also highlighted that patients with heart failure with preserved ejection fraction (EF) were more likely to be admitted to medicine, which he said might be an indication that clinicians are underestimating severity of illness in such patients. Dr. Goyal is director of the heart failure with preserved EF program at Weill Cornell Medicine.

“Perception of severity of illness is particularly relevant as it relates to heart failure with preserved ejection fraction,” he said. “Many clinicians incorrectly equate a normal ejection fraction with reduced severity of illness and good prognosis and, as a result, patients with preserved ejection fraction are less likely to see a cardiologist during (and after) their hospitalization.”

Data show, however, that patients with preserved or reduced EF have similarly poor prognoses following hospitalization, Dr. Goyal and colleagues noted in their study. In addition, compared with reduced EF patients, those with preserved EF often do not derive as much benefit from standard heart failure therapies, such as beta-blockers and renin-angiotensin inhibitors, and have a higher noncardiac comorbidity burden.

At UCI Medical Center, ED physicians follow a defined clinical pathway to direct patients to the appropriate admitting service, said Dr. Amin.

“Patients with recurrent heart failure and those with other problems (such as pulmonary embolism, infection, or chronic obstructive pulmonary disease) go to our hospitalist service,” he said. “Patients with nuance (such as arrhythmia or ischemia) go to our advanced heart failure service.”

Admitting decisions may also be impacted by the size or robustness of an institution's hospitalist program, said Dr. Greene. For example, a large hospital might have enough hospitalists for some to specialize in heart failure care. “There is wide variation in the type of care models where heart failure patients are being admitted,” he said.

At Duke, cardiologists are called to the ED on almost every heart failure case to confirm diagnosis and guide triage, said Dr. Greene. Patients are sent to different subservices within cardiology depending on the specific diagnosis, such as advanced heart failure or cardiogenic shock. Some patients do go to the internal medicine or hospitalist services.

“A minority of patients have particularly complex comorbidities, such as end-stage renal disease or severe lung disease,” he said. “Even though they have clinical heart failure, they may be better managed primarily on a noncardiology service with cardiology as secondary consultant.”

Addressing racial disparities

Ideally, patients would always get assigned to the service that can best meet their specific medical needs, but recent research on racial disparities suggests otherwise.

One retrospective study of over 100,000 ICU admissions for heart failure across the country found that Black patients were less likely than White patients to be referred to cardiology care. Primary care by a cardiologist was also associated with higher survival, irrespective of race, according to the results published in the May 2018 JACC: Heart Failure.

Although Black patients had higher overall rates of hypertension, comorbidities, and underinsurance, the racial differences persisted after controlling for those variables, said the study's lead author, Khadijah Breathett, MD, MS, an advanced heart failure/transplant cardiologist, physician-scientist, and assistant professor of medicine at the University of Arizona in Tucson. More Black patients were on Medicaid, she noted, which may limit access to subspecialty care due to lower reimbursement compared with Medicare and private insurance.

Racial bias in admission decisions often results from ingrained institutional processes, structures, and ways of thinking that stigmatize and unfairly label Black and brown patients as non-compliant or not in need of specialty care, said Michelle Morse, MD, MPH, assistant professor at Harvard Medical School in Boston.

She was a senior author on the 2019 Circulation: Heart Failure study that found racial inequities in heart failure admissions with Black and Latino patients being more likely to be admitted to hospitalists rather than cardiologists. A follow-up study showed that self-advocacy by White patients was associated with admission to the cardiology service.

Patients were also more likely to be seen by a cardiologist if they had received specialty care in the past. These findings illustrate how some patients get caught in a cycle of repeated admissions to general medicine, said Dr. Morse.

“If a patient is always admitted to general medicine, because that's where they went on a previous admission, and never connected to follow-up cardiology care, the cycle keeps repeating itself,” she said. “We need to change our processes so that a heart failure patient that is very complex or has been admitted multiple times automatically goes to cardiology and gets a higher level of care.”

The findings of the Circulation: Heart Failure study triggered much introspection among general medicine clinicians about how they care for heart failure patients, said Dr. Shannon.

“Knowing that Black and brown patients were being preferentially not admitted to cardiology led to a cultural shift,” he said. “Now, whenever we have a patient with heart failure on the general medicine service, everyone is much more attuned to potential inequities that might have led them to being admitted there and ensuring that they get the same level of care as patients admitted to cardiology.”

Adopting clinical pathways based on evidence-based criteria can also help prevent racial bias in admissions decisions, said Dr. Breathett.

“Race shouldn't be a part of the decision pathway unless it's related to social determinants of health that lead to offering support and ensuring equitable care,” she said. “There should be defined protocols so that patients automatically go to cardiology if certain criteria are met.”

Multispecialty team care

Universal access to subspecialty care is not always possible or practical, experts noted.

“From a quality and cost perspective we shouldn't isolate ourselves by specialty but instead figure out what we can do together to make gains,” said Dr. Amin, noting the high cost associated with heart failure care nationwide—approximately $31 billion annually, according to the CDC.

He sees the cost-effective solution as closer collaboration between hospitalists and cardiologists. “By having dedicated hospitalists work with cardiologists we might be able to reduce the average length of stay, optimize the patient, and reduce readmissions, thus lowering the cost burden while doing right thing for patients.”

Such multidisciplinary teams focused on heart failure management are being developed at many hospitals, with some success. Both inpatient and one-year mortality significantly improved after introduction of a multidisciplinary heart failure team, according to a study in a large tertiary hospital in the United Kingdom published in the January 2017 Open Heart. Improved use of evidence-based therapies and more intensive diuretic use may have contributed to better outcomes, the authors noted.

In addition to hospitalists and cardiologists, such multidisciplinary heart failure teams bring together a wide range of expertise, including pharmacists, nurses, social workers, and patient care coordinators, said Dr. Greene.

“Most members of the inpatient team have a good understanding of outpatient care for heart failure, and what care for these patients looks like immediately after discharge. This helps optimize difficult transitions of care because many of us work in both the inpatient and outpatient settings,” he said. Also critical is having team members who are immersed in cardiology care, he said, such as pharmacists who focus on cardiology-specific drugs and medication interactions.

It's important to recognize the value of postdischarge services in driving good outcomes, added Dr. Morse.

“Part of the reason that readmission rates are lower in cardiology service is that they have additional resources, such as follow-up nurses who help with medications and programs to get more intensive therapy,” she said. “Patients benefit from the higher level of support that comes with cardiology admission that often is not part of the general medicine service.”

Recognizing this, Brigham and Women's recently initiated a quality improvement project focused on heart failure care in general medicine that adds extra postdischarge services such as vouchers for transportation, follow-up medication reconciliation, and weight check-ins. A goal is to expand access to the system's existing heart failure care pathways to more patients.

“We have a terrific multidisciplinary approach to cardiovascular care for patients who are already plugged into cardiology care,” said Dr. Shannon, who leads the initiative. “We want to connect more folks to those resources, especially underrepresented Black and Latinx patients, so we can break the cycle of readmission that often occurs with heart failure patients.”

Dr. Morse added that the team at Brigham believes that color-blind approaches to this problem are inadequate and that Black and Latino patients should receive preferential access to the cardiology service to remedy unequal treatment over the past decade.

At Duke, staff hospitalist and ACP Member, Cara O’Brien, MD, is partnering with cardiology fellow Vishal Rao, MD, to launch a virtual cardiology consultation program focused on getting patients access to cardiology care while they are in the hospital for other reasons, such as hip fracture.

“Heart failure may not be an active issue for these patients, but it's on their problem list, and we can use the hospitalization to optimize their goal-directed medical therapy,” she said. “Cardiologists will be brought in virtually to look over patients' labs and medication lists and offer follow-up recommendations.”

Dr. Breathett also mentioned that greater access to subspecialists through telemedicine seems likely to be part of the solution to improving inpatient heart failure care. “We want to ensure that each patient receives optimal guideline-based care irrespective of their demographic,” she said.

Heart failure-specific training and education programs for hospitalists, emergency physicians, pharmacists, and other clinicians may also expand access to care and help improve outcomes, said Dr. Amin. For example, the Heart Failure Society of America is introducing a Heart Failure Certification program focused on training hospitalists and other clinicians to work on multidisciplinary heart failure teams in 2021.

Whether on a national or individual level, cardiologists can provide guidance to hospitalists in key areas to improve heart failure care, particularly uptitrating guideline-directed medical therapy, referring patients for advanced therapies, and managing volume overload in the presence of chronic kidney disease, said Dr. Goyal.

“Cardiologists need to formally partner with hospitalists to ensure high-quality care,” said Dr. Goyal. “Given the sheer number of heart failure hospitalizations, the reality is that many patients will primarily be cared for by hospitalists.”