Who's better at followup, FPs or specialists?

U of A cardio study says both, but casts doubt on FP-only care

By Owen Dyer

The latest example of this appears in the January 18 issue of the Canadian Medical Association Journal. Researchers from the University of Alberta followed 3,136 congestive heart failure (CHF) patients after discharge from hospital with a new diagnosis of CHF and found that two followup physician heads are better than one when it comes to outcomes — but family docs shouldn't be left to their own devices.

Considering the current trend is to direct more followup care away from specialists and toward GPs, this finding has great resonance for time-strapped physicians on both sides. Twenty-four percent of the study group were seen by a family physician alone, and 42% by both a family physician and a specialist; 1% were seen by just a specialist. Both groups, naturally, fared much better than the unlucky 34% who received no followup cardiovascular care, but there were dramatic differences between them. Patients who relied solely on their family doctor had fewer outpatient and emergency visits, and fewer hospital readmissions than those who also saw a specialist. Unfortunately, they also died more, with 28% succumbing in the first year after diagnosis, compared to 17% in the combined care group.

This, say the authors, occurred despite the fact that the patients who also saw a specialist bore a heavier burden of comorbid conditions. In fact, when the data was adjusted to account for such conditions,it suggested that heart failure patients followed up by their family doctor alone are twice as likely to die in their first year after hospital treatment as are those who also continue to see a specialist.

"Why did outcomes differ by care provider?" ask the authors in their paper. "Patients cared for by both a specialist and an FP have more contacts with the medical community; thus, there are more opportunities for deterioration in status to be detected, for medications to be added or titrated, or for the nonpharmacologic therapies that are important in CHF to be reinforced."

SPENDTHRIFT MDs?
The study was accompanied by an editorial comment from British cardiologist John Cleland who says that specialists need to take their fair share of responsibility for the situation. He argues they've undermined their own position by squandering resources. "We already know that haphazard care fails many patients and is expensive," he writes, "but improvements are inhibited by the fear that specialists will throw all the available technology at patients regardless of proof of safety, efficacy or affordability. Specialists must show that they can act responsibly as guardians of healthcare resources, which must be used wisely to gain the trust of those who fund health care."

IN AN IDEAL WORLD
Dr Paul Armstrong, one of the authors of the Alberta heart failure study and an Edmonton cardiologist, says that while every heart failure patient would be followed by a specialist in an ideal world, we must operate with a fixed number of specialists, and there is no point in diluting their effort by simply dumping more patients onto each specialist. "Some of the load has to be borne by other professionals," he says from his Edmonton office. "Obviously, family physicians have a huge role to play. But I think they need help in fulfilling that role."

But he admits it's not always easy to share knowledge across disciplines. "Cardiovascular followup is very complicated these days," he says. "I think there's a lot of promise in telemedicine, handheld computers and so on. But really we need an approach that is integrated at every level."

THE CANCER EXAMPLE
Modern cancer care is generally closer to the kind of holistic approach advocated by Dr Armstrong. Many cancer centres are actively working to integrate family physicians more closely in the treatment process. The Tom Baker Cancer Centre in Calgary, for example, has developed a standardized letter to ensure that all relevant information is passed on to the family physician.

The evidence suggests that unlike CHF patients, cancer patients fare quite well in the sole care of a family physician. Dr Eva Grunfeld of Dalhousie University, a longtime advocate of the family physician's role in cancer, presented research to the Family Medicine Forum in Toronto two months ago which showed that breast cancer survivors did just as well in the care of their family physician as did those in regular Ontario regional cancer centre programs.

Over five years, the 965 women in the study suffered the same number of serious clinical events regardless of which type of physician was responsible for their care. Such events are the main reason why oncologists are reluctant to release patients, she told the conference. "They're worried about potentially preventable serious clinical events. These are spinal cord compression, pathological fractures, hypercalcemia, uncontrolled local recurrence, brachial plexopathy and poor functional status."

The information the family doctors needed was contained in a simple, one-page set of guidelines. Overall, said Dr Grunfeld, the approach "was acceptable to patients, to surgeons and to some oncologists."

It all comes down to the number of doctors, of course — there is only so much time available to each patient. We had better make the most of the resources we have, says Dr Armstrong, because we are swimming against the tide.

"The problem of followup of chronically ill patients is already far worse than it was twenty years ago, because more are surviving, and people are living longer."