Association Between Cardiologist Ambulatory Workload and Evidence-Based Therapy for Heart Failure

Most eligible patients are not prescribed guideline-directed medical therapy for heart failure with reduced ejection fraction (EF). Increased time pressures for providers in the ambulatory setting may contribute to these shortfalls. We assessed the association between cardiologist ambulatory workload and guideline-directed medical therapy prescription for patients with heart failure with reduced EF.

This was a cross-sectional study of patients with heart failure with reduced EF (EF ≤40%) seen by a cardiologist from October 1, 2022, to September 30, 2023, using deidentified administrative and electronic health record data from Optum Labs Data Warehouse, which includes data from multiple health systems across the United States. The primary exposure was ambulatory workload, measured as the average number of visits per day, categorized into quartiles. The primary outcome was "comprehensive quadruple therapy," defined as prescription for all 4 guideline-directed medical therapies: β-blocker; angiotensin receptor-neprilysin inhibitor; mineralocorticoid receptor antagonist; and sodium-glucose cotransporter 2 inhibitor. Analyses were conducted using generalized estimating equations, adjusted for demographic and clinical variables.

Overall, 40 173 patients were seen by 881 cardiologists (median ambulatory workload, 9.1 patients per day; interquartile range=5.1-13.0). The percentage of patients prescribed comprehensive quadruple therapy was higher among patients in lower quartiles (quartile 1: 14%; quartile 2: 9.7%; quartile 3: 8.9%; quartile 4: 7.4%; P<0.001). In adjusted analysis, there was a graded association between lower workload quartile and higher odds of comprehensive quadruple therapy, compared with the highest quartile (odds ratio [95% CI], P value=quartile 1: 1.35 [1.09-1.66], 0.008; quartile 2: 1.20 [1.00-1.43], 0.050; quartile 3: 1.11 [0.93-1.32], 0.28; quartile 4 [reference]).

Seeing a cardiologist with lower ambulatory workload was associated with increased prescribing of guideline-recommended, life-saving therapy in patients with heart failure with reduced EF. Current models that incentivize more visits per day may negatively impact care in the ambulatory setting.