Patients At Community Health Clinics Less Likely To Be Referred To Cardiologist

Researchers from the National Heart, Lung, and Blood Institute (NHLBI) and Harvard Medical School reviewed the electronic medical records of 9,761 adult patients who received primary care at either hospital-based clinics or community-based primary care centers affiliated with two large academic medical centers between 2000–05. They analyzed the likelihood of obtaining initial and ongoing cardiac consultations by site of primary care and socio-demographic characteristics.

Overall rates for cardiology consultations were higher than previously reported — 79.6 percent of coronary artery disease (CAD) patients and 90.3 percent of congestive heart failure (CHF) patients. However, patients seen at the community-based health centers received fewer cardiology consultations than those seen at hospital-based settings, while women seen in all settings were less likely than men to be referred to a cardiologist.

The analysis for initial consultations over the five-year study period showed:

• CAD patients seen at the community-based health centers were 21 percent less likely to receive an initial cardiology consultation than patients treated at hospital clinics, while CHF patients were 23 percent less likely.
• Women with CAD were 11 percent less likely than men to be referred for an initial cardiology consultation, and women with CHF were 7 percent less likely.
• African-American and Hispanic patients were just as likely or more likely than their white counterparts to receive an initial cardiology consultation.

For ongoing cardiac consultations, researchers found that:

• Women had 15 percent fewer follow-up consultations than men.
• Patients treated at community-based health centers had 20 percent fewer follow-up consultations than those treated in hospital-based practices.
• African Americans and Hispanics with CHF received about 13 percent fewer follow-up consultations.
• Women, African-American and Hispanic patients with fewer follow-up consultations consistently scored worse on cardiac performance measures over the five years of the study.

“Access to a cardiology specialist is often a prerequisite for obtaining cardiovascular procedures,” said Nakela Cook, M.D., M.P.H., lead author of the study and a clinical medical officer at NHLBI. “In this group, consultation with cardiology specialists improved the quality of medical care and reduced disparities in treatment of women.”

Researchers considered the number of follow-up consultations as a proxy for co-managing cardiovascular patients — meaning that both their primary care physician and cardiologist were treating their condition and monitoring their progress.

“This was underscored by the fact that women who had consistent follow-up consultations achieved cardiac performance goals equal to those of men despite having lower scores at the outset,” Cook said. “Consultation seemed to narrow the gender gap.”

The site where patients receive their primary care is particularly relevant in understanding the disparities, because community-based health centers serve a large proportion of racial and ethnic minorities who are either uninsured or have Medicaid.

“We need to raise awareness that differential referral patterns exist and that these differing patterns may affect the quality of care received,” Cook said. “Overall, the quality of care in these ambulatory settings was sub-optimal. What we have learned from studies of quality of care in the hospital or at hospital discharge is that placing focus on quality improves achievement of performance measures.”

Government reimbursement was not a factor in the disparities found in this study. Researchers found that Medicare and Medicaid recipients were more likely to obtain a consultation than those privately insured. They said the disparities they noted may be larger in settings outside academic medical centers.

Leveling the consultation access playing field will take a multilevel approach — combining increased patient awareness, removal of access barriers and provider/system changes to identify and refer appropriate patients for consultation for ongoing management of heart disease, Cook said.

“The last thing that anyone wants is to simply increase the number of patients referred for consultation,” she said. “We need to figure out who needs specialty care and when, and provide it to them. There may be a role for targeted increased utilization of cardiology consultation and referral among particular patients or groups where most appropriate.”

Co-authors are John Z. Ayanian, M.D., M.P.P.; Endel John Orav, Ph.D.; and LeRoi S. Hicks, M.D., M.P.H. Individual author disclosures can be found on the manuscript.

The Agency for Healthcare Research and Quality partially funded the study.