Outpatient cardiology care improves survival odds after heart attack

November 20, 2002

BOSTON, MA -- Elderly heart attack patients who visit a cardiologist's office in the months after leaving the hospital are less likely to die within two years than patients who visit only their primary care doctor, a study by Harvard Medical School researchers finds. And patients who visit both a cardiologist and a primary care doctor have even better outcomes than those who visit only a cardiologist.

Previous research suggests that patients may live longer if they are under a cardiologist's care while hospitalized for myocardial infarction. In the new study, John Ayanian, Harvard Medical School associate professor of medicine in the Department of Health Care Policy, and colleagues examined the records of patients covered under Medicare (with an average age of 74) to see whether this holds true for outpatient care. Co-authors of the study, published in the Nov. 21 issue of the New England Journal of Medicine, are: Mary Beth Landrum, assistant professor of biostatistics; Edward Guadagnoli, associate professor; and Peter Gaccione, senior programmer, all in the Health Care Policy department.

"Physicians providing ambulatory care to patients who survive a heart attack have a very important role to play," Ayanian, also a practicing physician at the Harvard Medical School affiliated Brigham and Women's Hospital, said. "They can monitor and treat patients for complications, such as chest pain or depression, that often develop after patients leave the hospital."

From an initial group of 35,520 patients who survived a hospitalization for myocardial infarction in 1994 and 1995, the investigators created two groups of 10,199 patients each: one group received outpatient care from cardiologists and the other group did not. Each patient was matched to another in the opposite group who was very similar in ways that affect the estimated probability of visiting a cardiologist after discharge. This matching procedure -- based on demographic and clinical variables, hospital care, medications at discharge, and hospital characteristics -- was used to make the two groups as similar as possible. That way, the researchers could be more confident that differences in outcome were related to differences in outpatient care itself, not to variation in factors that influence patients' choice of outpatient care. (The authors caution, however, that factors they did not measure may have affected the results to some extent.)

Of patients who visited only an internist or family practitioner, 18.3 percent died within two years, compared with 14.6 percent of those who had seen a cardiologist. Patients who saw a cardiologist were more likely to undergo coronary procedures, exercise testing, and cardiac rehabilitation, but were not more likely to receive effective cardiovascular medications. Ayanian added, "We were concerned to find that over half of patients, regardless of whether they were seeing a cardiologist or primary care physician, were not receiving beta-blockers or cholesterol-lowering drugs that have been shown to reduce mortality after a heart attack. Patients' outcomes could likely be improved with greater use of these effective drugs."

The survival benefit associated with cardiology visits was greatest among patients who statistically were least likely to see a cardiologist, including those who were older, female, or black, had co-existing illnesses, or were treated in hospitals not offering invasive coronary procedures.

"Among patients who saw a cardiologist, two year mortality was lower for those who also saw an internist or family practitioner," the authors note, "indicating that concurrent, and ideally, collaborative ambulatory care by generalists and specialists may provide the best prospects for improving outcomes after myocardial infarction."
This research was sponsored by the federal Agency for Healthcare Research and Quality.

Harvard Medical School has more than 5,000 full-time faculty working in eight academic departments based at the School's Boston quadrangle or in one of 47 academic departments at 17 affiliated teaching hospitals and research institutes. Those HMS affiliated institutions include: Beth Israel Deaconess Medical Center, Boston VA Medical Center, Brigham and Women's Hospital, Cambridge Hospital, Center for Blood Research, Children's Hospital, Dana-Farber Cancer Institute, Harvard Pilgrim Health Care, Joslin Diabetes Center, Judge Baker Children's Center, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, Massachusetts Mental Health Center, McLean Hospital, Mount Auburn Hospital, Schepens Eye Research Institute, Spaulding Rehabilitation Hospital.

Harvard Medical School

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