Why You Need A CHF Specialist

 Jon's Take On CHF Specialists

You're not just facing a question of "Do I need a specialist?" You're facing, "Which specialist is right for me?" Consider it point by point:

  1. If he intimidates you, you will hesitate to ask questions. This is bad
  2. If he misses a pre-existing condition (especially a documented one), he may prescribe the wrong drug or treatment, especially in an emergency; Or he may misdiagnose you. This is bad
  3. If he does not explain the condition or disease; its causes, treatments, symptoms and how to deal with it, then he is treating a chart or a number or a condition, not a person with a life just as important as his. This is bad
  4. If he is in a hurry,... Well, this is bad

Your doctor may have all the technical know-how and education in the world, but that does not make him a good doctor or the right doctor for you. He may be a better administrator than doctor. This may account for his exalted position in his "community." Maybe once he got a "name" he got too busy and forgot the humane and subtle requirements of treating "people" rather than diseases. It happens.
     I don't give a hoot what a doctor's reputation is when my life is on the line. If he's in a hurry, thinks he is perfect, misses parts of my problem, or isn't willing to take enough time to explain his opinion and his reasons for it - in plain English - to me, he's doing me no good at all.
     The key is to get a CHF specialist who treats you, not the illness. He should take time to make himself and his knowledge available to you. Doctors work for us! They're not in charge of us, we are in charge of them. We pay them for specialized knowledge and to a large degree, judgment gained through experience. If they aren't paying attention to you as a person; your conditions, your fears, and anything else important to you, they may not realize that you pay their salary!
     My CHF cardiologist comes in, sits down, asks about my daughter, my wife and my web site, then asks, "How do you feel?" He then questions me at length about just that - how I feel. Then he gives me a physical exam including checking how distended my neck veins are. We discuss symptoms, test results, upcoming tests, supplements, and treatments. Is this how the doc treats you? If not, maybe it's worth doing some serious doctor shopping.

 How Do You Find A CHF Specialist?

 How To Shop For A Doctor

Daniel Ford, MD, MPH, January 19, 2000 - A referral from a friend may not be a good way to find your next doctor. If you're lucky and know someone in the health field, you might find out which doctors are highly regarded by their peers. If you're moving, a doctor might recommend someone in your new location. That doesn't mean they are right for you.
     On the practical side, some people first choose a hospital, then find out which doctors have privileges there. Hospitals with a reputation to maintain - like big name medical centers - generally give privileges to doctors with the best credentials.
     On the personal side, the way a doctor treats you during an office visit can tell you a lot about how well you'll be able to work together to maintain your health. Here are some things to consider:

  1. Insurance coverage - Choose a doctor who's approved by your insurance plan. Under a managed care plan, a primary care doctor supervises all of your care, seeing you for checkups and acute episodes. He gives referrals to specialists
  2. Credentials and experience - If I were looking for a new doctor, I'd ask about his medical school and residency training. The residency setting can be as important as the school attended. A doctor who trained at a large, busy hospital has seen a greater number and variety of cases, gaining wider experience
  3. Experience - Do you want a doctor fresh out of medical school? He might be more familiar with recent developments but have little real-world experience. Do you want a seasoned pro? He may not be as current on medical advances but has a lot of clinical experience. Regardless, choose a doctor who is board certified. That means he has extra training beyond medical school and residency. To check on a doctor's certification, visit the web site of the American Board of Medical Specialties or call 1-800-776-2378
  4. Convenience and office policies - Small things can make a big difference. Consider office hours and location, response to after-hours calls, policy on returning calls and answering questions over the phone or via e-mail, and ability to accept unscheduled, same-day appointments when necessary.
  5. Personality - To find out what's important to new patients in my own practice, I ask two questions: What do you want from a doctor? What has bothered you most about doctors you've seen in the past? The response to the first question usually includes technical competence and good listening skills. Complaints usually include lack of listening skills and a tendency not to return phone calls.

Communication is a key issue. Last summer, a study in the Journal of the American Medical Association showed that patient satisfaction is closely related to how much a doctor encourages patients to be part of decision making. To be an real partner in your own health care, you need to establish an open and comfortable working relationship with your doctor.
     How do you judge whether such a relationship is possible before signing on with a new doctor? When you first meet a doctor, I suggest asking these 10 questions:

  1. What do you think are the strengths and weaknesses of your practice?
  2. Have you formally measured the quality of care in your office or done anything recently to improve it?
  3. How do you approach patient education?
  4. When would you suggest a second opinion?
  5. How do you feel about alternative therapies and medicines?
  6. How do you keep up with new developments in medicine?
  7. If I had a choice between treatments, how would we work together to make a decision?
  8. Do you encourage patients to ask direct questions?
  9. Would you be offended if a patient questioned your judgment?
  10. Do you encourage patients to find information on their own about health problems?

Many patients are reluctant to ask such questions for fear they'll alienate the doctor and compromise their care. Remember - if the doctor bristles at these questions, consider that an early warning of a bad match.

 Cardiologists Vs Family Doctors

December, 1999 - Official guidelines have been issued for diagnosing and treating patients with poor left ventricle function, the most common type of heart failure. These guidelines are a nationally recognized yardstick for measuring quality of CHF care.
     The guidelines suggest testing to measure heart function. Any patient with an EF less than 40% should take an ACE inhibitors. ACE inhibitor dose should be slowly raised to high enough levels to reduce mortality regardless of symptoms. Patients with CHF who also have a-fib should take Coumadin (warfarin).
     As recently as 1990, 83% of CHF patients were cared for by general internists or family doctors with no formal cardiology training. General internists and family doctors are less knowledgeable about advances in CHF therapy, according to 2 surveys. The first survey studied how well board-certified cardiologists and board-certified family doctors really use accepted guidelines to diagnose and manage CHF in their daily practice.
     Previous survey studies have been limited by the fact that doctors often overestimate their own compliance with guidelines. The difference between how doctors report their own practices and actual practices has been noted in several studies that compare survey results to patient charts. To avoid this, we used specific case scenarios to study doctors' patterns.

Methods
Surveys were mailed to 500 family doctors and 500 cardiologists. They were randomly selected from the American Medical Association's physician master file. Four cases were presented, followed by questions about tests, diagnosis, drug therapy and/or the risks and benefits of drug therapy for the patient. Two hundred and twenty-four family doctors and 177 cardiologists replied. Forty-two family doctors and 14 cardiologists were not included because they did not see at least one CHF patient per week.
Volume:
The typical cardiologist saw about 12 CHF patients per week versus 4 CHF patients per week for the typical family doctor. Although 84% of cardiologists had reviewed the guidelines in detail, only 53% of family doctors had read the guidelines.
Case 1:
CHFer with chronic high blood pressure, heart enlargement, and diastolic dysfunction
  Cardiologists Family Doctors
would order an echo 98%90%
would order a MUGA 1%9%
considered measuring EF
very important in this patient
83%48%
would order a nuclear stress test
for measuring ischemia
43%30%
would refer this patient to a cardiologist 48%
would start patient on digoxin 6%24%
would start patient on
a ACE inhibitor
58%79%
would start patient on
a beta-blocker
44%9%

Doctors were then told that patient 1 had received an echocardiogram and the results showed moderate heart enlargement and a normal EF. Eighty-seven percent of cardiologists versus 46% of family doctors then assumed symptoms suggested diastolic dysfunction.

Case 2:
CHFer with typical history of CHF developing from worsening systolic dysfunction after an acute heart attack
  Cardiologists Family Doctors
would order an echo 91%89%
considered measuring EF
very important in this patient
77%62%
would order a nuclear stress test
for measuring ischemia
58%41%
would refer this patient to a cardiologist 75%
Doctors were then told that patient 2 had received an echo and the results showed very little heart wall motion and moderately to severely reduced EF
  Cardiologists Family Doctors
presumed symptoms to be caused by
left ventricular dysfunction
66%42%
presumed symptoms to be caused by
combined systolic & diastolic dysfunction
26%34%
presumed symptoms to be caused by
silent ischemia
7%5%
would start patient on digoxin 60%73%
would start patient on
an ACE inhibitor
83%99%
would start patient on
a beta-blocker
9%20%
would start patient on
a calcium channel blocker
2%12%
Case 3:
A patient with a previous heart attack, new onset of heart failure, and blood pressure of 100/70mm Hg with no lightheadedness
  Cardiologists Family Doctors
believed an ACE inhibitor is safe
for this patient
80%43%
believed benefits of an ACE inhibitor
far outweigh risks in this patient
88% 56%
would start patient on
an ACE inhibitor
100%87%
 40% of family doctors considered the risks and benefits to be equal
Doctors were then asked to imagine that the patient's blood pressure was higher (130/80 mm Hg) and that blood creatinine level was 2.0mg/dL (a sign of poor kidney function)
  Cardiologists Family Doctors
believed an ACE inhibitor is safe
for this patient
44%18%
believed benefits of an ACE inhibitor
far outweigh risks in this patient
59%22%
would start patient on
an ACE inhibitor
98%75%
Case 4:
A patient with a history of anterior heart attack, EF of 25%, moderate heart failure, a-fib, and no outstanding reasons not to take a blood thinning drug
  Cardiologists Family Doctors
estimated risk of stroke
without Coumadin at
6%16%
estimated risk of major bleeding
with Coumadin use at
1%3%
did not think Coumadin use would affect
patient's quality of life
67%49%
believed benefits of Coumadin use
outweighed risks for this patient
85%50%
would not worry about starting
this patient on Coumadin
77%44%
would start this patient on Coumadin 99%85%
had personally seen a patient have a major
bleeding complication while on Coumadin
94%7%
Discussion

Our results suggest that some family doctors do not fully understand the difference between systolic and diastolic dysfunction, the 2 most common basic kinds of heart failure. In Case one - a typical case of diastolic dysfunction - only 46% of family doctors said diastolic dysfunction was the main cause, compared to 87% of cardiologists.
     In Case 2, we presented a typical CHFer - systolic dysfunction caused by a heart attack. Only 42% of family doctors identified systolic dysfunction compared to 66% of cardiologists. Only 76% of family doctors even mentioned systolic dysfunction as a contributing factor versus 92% of cardiologists.
     Not fully understanding the cause of CHF may be why family doctors and cardiologists place different value on measuring EF. Family doctors were much less likely than cardiologists to say that measuring EF was important. Family doctors may rate EF measurement as less important because they are not sure how to interpret the information the tests provide.
     Our results suggest that many family doctors do not distinguish between types of CHF. Cardiologists' treatment differed widely for the 2 cases. For case 2 (systolic dysfunction), 17% of family doctors did not recommend an ACE inhibitor despite all the evidence that giving one would improve survival! Family doctors were also much less likely to give an ACE inhibitor in a stable patient with low blood pressure or poor kidney function. In both cases, almost all cardiologists said they would give an ACE inhibitor, and cardiologists were much more likely to say that ACE inhibitors were safe in these patients.
     National guidelines stress the importance of using ACE inhibitors both in patients with mild low blood pressure and in those with mild kidney problems. Family doctors over-estimate the dangers of ACE inhibitor use in these patients. The same holds true for Coumadin use in CHFers with a-fib. Cardiologists estimated annual risk of a major bleeding complication with Coumadin at 1%, which is accurate. Family doctors rated the risk much higher.
     Most CHFers are managed by primary care doctors. These doctors need more education about CHF causes and treatment. Studies have shown that sound guidelines may increase knowledge, but have little effect on actual practice. It is clear that education alone won't do it. Forcing the use of guidelines may be necessary.
 
Title: Variations in Family doctors' and Cardiologists' Care for Patients with Heart Failure
Authors: David Baker MD MPH, Risa Hayes PhD, Barry Massie MD, Carissa Craig BA
Source: Am Heart J 138(5):826-834, 1999

These Are The Official Guidelines
Agency for Health Care Policy and Research and American College of Cardiology guidelines for diagnosis and management of CHF:
 Cardiologists Versus CHF Specialists

1999 - One reason CHFers do not live better, longer lives is doctors' poor use of guidelines, including early diagnosis, ACE inhibitor use, and intensive follow-up. Compliance with guidelines is poor to this very day. Several studies show that cardiologists practice more closely to heart failure guidelines than family doctors. Now, CHF clinics under the guidance of CHF specialist cardiologists are being widely used. Many are connected to heart transplant programs. We surveyed CHF specialists and cardiologists.
     The CHF specialists were 118 American cardiologists who were main investigators in published CHF trials. None were older than 65, within 5 years of medical school graduation, or practicing in communities of less than 100,000. A 32 question survey was used. Questions focused on patients with CHF caused by left ventricular systolic dysfunction and an EF less than 40%. CHF specialists saw more CHF patients than cardiologists. Most doctors in both groups (93% and 81% of general cardiologists) said they were aware of the CHF treatment guidelines.
     In patients being seen for the first time, cardiologists were much more likely to use a chest x-ray. CHF specialists were more likely to use an echocardiogram. CHF specialists used several tests more often, including MUGA, Vo2max, cath (including right heart cath), and heart biopsy.
     In patients with mild to moderate CHF, CHF specialists used ACE inhibitors more often. In all cases, CHF specialists were more likely to start a 3-drug regimen consisting of a a diuretic, an ACE inhibitor, and digoxin. For maintenance therapy in these patients, CHF specialists used ACE inhibitors more often (91%) than cardiologists (80%). In severe CHF, both groups used ACE inhibitors alike. CHF specialists were more likely to use digoxin, hydralazine, and beta-blockers. Calcium channel blocker use was low.
     There were significant differences in the way ACE inhibitors were used. Seventy-five percent of CHF specialists but only 35% of cardiologists raised to high doses. Cardiologists were more likely to raise dose according to how symptoms responded instead of raising to high dose regardless. This resulted in 50% of CHF specialists' patients taking high doses compared to 30% of cardiologists' patients.
     Eighty-seven percent of CHF specialists but only 52% of cardiologists said they would start an ACE inhibitor in a patient with poor kidney function. Sixty-four percent of CHF specialists but only 45% of cardiologists said they would continue an ACE inhibitor if kidney function worsened. CHF specialists are more likely to start or continue ACE inhibitors in patients with poor kidney function.
     Cardiologists were more likely to use repeat chest x-rays (12% versus 4%) or echocardiograms (30% versus 22%) to monitor stable patients. CHF specialists were more likely to measure exercise capacity (Vo2max) at regular intervals (18% versus 3%).

Discussion

Trials have shown that taking ACE inhibitors, vasodilators, digoxin, and beta-blockers reduce complications and mortality in CHFers; But there has been no real improvement in prognosis of CHFers. This may be because doctors do not follow follow guidelines.

In a previous report, we found that cardiologists followed guidelines better than internists or family doctors
  Cardiologists Internists Family Doctors
measured EF 92% 69% 61%
used ACE inhibitors in patients with mild to moderate CHF 80% 71% 60%
used ACE inhibitors in patients with severe CHF 89% 84% 76%
raised patients to the higher recommended doses 35% 12% 3%

Now we see that CHF specialists follow guidelines better than cardiologists. CHFers may be better managed by CHF specialist cardiologists They are more likely to order echocardiograms and less likely to rely on chest x-rays than cardiologists. They use tests like MUGA, right heart cath, left heart cath, Vo2max, and heart biopsy more often. For instance, an echocardiogram was the first test used to confirm a CHF diagnosis by 15% of general practitioners, 22% of internists, 48% of cardiologists, and 73% of CHF specialists.
     CHF specialists treat CHF patients more aggressively. General practitioners reported that 60% of their mild to moderate CHF patients were taking ACE inhibitors; internists 71%, and cardiologists 80%, compared to 91% by CHF specialists. CHF specialists were also more likely to raise the ACE inhibitor dose higher, which has been proven to be much more effective. Greater use of other meds like digoxin, hydralazine, and beta-blockers was also seen with CHF specialists.
 
Title: Self-Reported Differences Between Cardiologists and Heart Failure Specialists in the Management of Chronic Heart Failure
Source: Am Heart J 138(1):100-107, 1999

 Heart Failure Clinics

September 10, 1999 - It may be that proven CHF therapies like ACE inhibitors are not well used. At the University of Alberta Hospital, a Heart Function Clinic now exists. We studied our experience managing CHF in this clinic. We also compared patients with left ventricular systolic dysfunction to those with "preserved" left ventricular function.
     We studied 628 consecutive adult patients being evaluated for CHF at our CHF clinic. The final study included 566 patients. Each patient was treated by the attending clinic physician. No drug protocols were required. EF measurements by echo, MUGA or cath were done for all patients.
     Patients were said to have systolic dysfunction if their EF was less than 45%. If patients had an EF higher than 45% or if their problem was the heart's relaxation phase (diastolic dysfunction - see The Manual), they were said to have "preserved systolic left ventricular function."
     We recorded cause and symptoms of CHF, heart class, other health conditions, arrhythmias, blood pressure, heart rate, blood test results for potassium, creatinine, and hemoglobin levels, and current meds. These were entered into a database. Average follow-up lasted 518 days.

Cause
Most patients (65%) had moderate to severe systolic dysfunction with an EF less than 40%, but 22% had EF greater than 45%. Ischemia (poor blood flow to the heart) and high blood pressure were the most common causes. Idiopathic cardiomyopathy (13%), valve disease (7%), and alcoholic cardiomyopathy (2%) were less common. No patients had hypertrophic or restrictive cardiomyopathy
Meds
Patients with preserved systolic function were not given ACE inhibitors, diuretics, aspirin, or amiodarone as often; and were treated more often with beta-blockers and calcium channel blockers. Eighty-three percent of all patients got ACE inhibitors. The most commonly prescribed ACE inhibitors were enalapril/Vasotec (10mg/day), lisinopril/Prinivil (10mg/day), and captopril/Capoten (62mg/day)
Mortality
During follow-up, 148 of the 566 patients died; 82% from heart-related causes and 18% from other causes. Although patients with low EF were more likely to die, survival in patients with systolic dysfunction versus preserved systolic function was not much different
  One-year survival rates At 2 years, survival rates were At 3 years, survival rates were
Class 1 CHFers 95% 87% 84%
Class 2 CHFers 93% 83% 77%
Class 3 CHFers 83% 69% 60%
Class 4 CHFers 70% 52% 34%
Discussion

We found that a specialized outpatient CHF clinic provides very good therapy. That 83% of patients got ACE inhibitors is a huge improvement from the 32 to 54% reported in surveys. Our survival data are at least as good as CHF trials. Effectively applying proven therapies reduces mortality.
     CHFers with near-normal left ventricular systolic function form a distinct subgroup. Although they tended to be older, have more history of high BP and more women, there was no way to identify these patients by physical exam alone, which proves the need to measure EF in all CHF patients. The mortality rates in our patients with preserved systolic function were about the same as those with systolic dysfunction.
     Our data suggest that a specialized outpatient CHF clinic can improve patient outcomes.
 
Title: Insights Into the Contemporary Epidemiology and Outpatient Management of Congestive Heart Failure
Source: Am Heart J 138(1):87-94, 1999

 Who Should Treat In The Hospital?

August 13, 1999 - Hospitalized CHF patients treated by cardiologists are less likely to be readmitted to the hospital and have better quality of life than those treated by other types of doctors. Researchers reported their findings in the August issue of the journal CHEST.
     Diuretics and digoxin have long been the most common drugs used for heart failure. Major trials have shown that ACE inhibitors can help CHF patients have longer, more active lives. These drugs help heart function by easing the load on a failing heart.
     Authors of the study said that new CHF treatments require care from CHF specialists. At the same time, they note that managed care plans are increasing the role of PCPs in CHF treatment. This study involved 2,454 patients at 10 community hospitals in 3 groups:

  1. patients not treated by a cardiologist
  2. patients whose attending doctor was a cardiologist
  3. patients who had consultation from a cardiologist but whose attending doctor was not a cardiologist

Patients who survived their hospital stay were followed for 6 months. Researchers analyzed treatment and outcomes. Patients treated by a cardiologist or who had a consult by a cardiologist were much more likely to have the cause of their CHF documented in their charts. They were also more likely to have echocardiograms or MUGAs, and they were more likely to get diet counseling and management strategies. These patients were also more likely to get ACE inhibitors. When compared to treatment by non-cardiologists, direct care by cardiologists meant lower risk of readmission and better quality of life. However, hospital charges were higher and there was little difference in mortality rates and length of hospital stay.
 
Title: Heart Failure Patients Do Better When Treated By Cardiologists
Source: Reuters Health

 Do Specialists Cost More?

April 14, 2000 - Cardiologist care of CHF patients is not more expensive or resource-intensive than care given by internists and family doctors. Dr. Edward Philbin got information on all patients discharged from New York state hospitals in 1995 with a diagnosis of heart failure.
     Of 236 acute-care hospitals, 44,926 patients qualified for the study. "Of these, 23% were cardiology patients, 63% were internal medicine patients, 11% were family doctor patients, and 3% were patients of other kinds of doctors," the authors say. Patients in the "other" group were usually managed by surgeons. Cardiologists' patients did not have longer LOS (length of stay) or higher hospital charges than patients cared for by non-specialists.
     Average LOS for patients of cardiologists was 9.4 days, compared to 9.5 days for patients under internal medicine care. For patients cared for by family doctors the average LOS was 8.6 days, and for "other" doctors it was 11.7 days. Average hospital charges for cardiology patients were $11,956 and for internal medicine patients were $11,556. Costs for family practice patients were $9,718 and patients cared for by other doctors cost $19,449.
     Nine percent of cardiology patients had a cath compared to 3% of internal medicine patients and 2% of family practice patients. Eleven percent of "other" doctors' patients had caths. Mortality and readmission rates were similar in all 4 groups.
     "Concerns that specialists' care is more expensive is probably a major barrier to specialty care in this country," the researchers write. "But our work does not support the notion that cardiologists' care for CHF is too expensive."
 
Source: Am Heart J 2000;139:491-496, Reuters Health

All information on this site is opinion only. All concepts, explanations, trials, and studies have been re-written in plain English and may contain errors. I am not a doctor. Use the reference information at the end of each article to search MedLine for more complete and accurate information. All original copyrights apply. No information on this page should be used by any person to affect their medical, legal, educational, social, or psychological treatment in any way. I am not a doctor. This web site and all its pages, graphics, and content copyright © 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004 Jon C.

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