Even without exercise testing data, diagnostic tests to assess coronary artery disease seem to be underutilized. Although the cost of a single episode of care may be less when a generalist provides care, if the correct diagnosis is not made or appropriate resources are not used, the long-term costs may be greater. Of additional concern is the apparent underutilization of angiotensin-converting enzyme inhibitors. Although the findings have been consistent, several reports indicate that cardiologists tend to care for a younger population, a higher percentage of male patients, and patients of higher socioeconomic status. This could explain some of the observed differences.
Outpatient care is integral to the appropriate management of patients with congestive heart failure.
Heart failure is a chronic disease process for which most care is delivered in the outpatient setting. Titration of diuretics to maintain target volume status, education about diet and exercise, adjustment of vasodilator therapy, and initiation and adjustment of -adrenergic blocker therapy require close attention by experienced practitioners to minimize morbidity, mortality, and admission to the hospital. As future studies of care of patients with congestive heart failure are designed, the focus should be on appropriateness of care directed by solid clinical evidence-based findings. The studies should address care in a longitudinal fashion, including outpatient care, rather than single episodes of inpatient care. Such information will allow us to focus on care that has less variation, requires less frequent hospitalization, is more cost-effective, and is associated with less morbidity and mortality.