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.
Key Findings
Results
Comprehensive quadruple therapy was prescribed to only a small minority of patients with heart failure with reduced EF, and the proportion fell across rising cardiologist workload quartiles.
Comprehensive quadruple therapy was defined as prescription of all 4 therapies: β-blocker, angiotensin receptor-neprilysin inhibitor, mineralocorticoid receptor antagonist, and SGLT2 inhibitor.
The unadjusted proportion in the lowest-workload quartile was almost double that in the highest-workload quartile.
Results
After adjustment, there was a graded association between lower cardiologist workload and higher odds of comprehensive quadruple therapy compared with the highest workload quartile.
Quartile 1: OR 1.35 (95% CI 1.09-1.66), P=0.008.
Quartile 2: OR 1.20 (1.00-1.43), P=0.050.
Quartile 3: OR 1.11 (0.93-1.32), P=0.28; quartile 4 was the reference.
Analyses used generalized estimating equations adjusted for demographic and clinical variables.
Results
The study cohort included 40,173 patients with heart failure with reduced EF seen by 881 cardiologists, with a median workload of 9.1 patients per day.
Interquartile range of ambulatory workload was 5.1-13.0 patients per day.
Patients had EF ≤40% and were seen by a cardiologist between October 1, 2022, and September 30, 2023.
Data came from the Optum Labs Data Warehouse, which has administrative and electronic health record data from multiple US health systems.
Results
Only the lowest workload quartile showed a statistically significant increase in odds of comprehensive quadruple therapy; the second quartile was borderline and the third was not significant.
Odds ratios decreased stepwise from 1.35 to 1.20 to 1.11 relative to the highest quartile.
Conclusions
The authors conclude that models incentivizing more visits per day may negatively impact ambulatory care quality.
The study was cross-sectional, so it shows association rather than causation.
Workload was measured as average visits per day per cardiologist, categorized into quartiles.
Time pressure in ambulatory visits is proposed as a contributor to underprescribing of guideline-directed medical therapy.
What This Means
This study looked at whether how busy a cardiologist's clinic is relates to whether patients with weakened-pumping heart failure receive the full set of four recommended, life-saving medicines. Using records from about 40,000 patients seen by 881 cardiologists across the US, researchers grouped cardiologists by their average number of patient visits per day (median about 9 per day).
Overall, few patients received all four medicines, but the rate was higher with less busy cardiologists: 14% in the lowest-workload group versus 7.4% in the highest-workload group. After accounting for patient demographic and clinical differences, patients of the least busy cardiologists had about 35% higher odds of receiving all four therapies than patients of the busiest cardiologists. The pattern was graded, though only the lowest group showed a clear statistical difference.
This research suggests that time pressure in clinic may contribute to gaps in prescribing guideline-recommended heart failure therapy, and that payment models that reward more visits per day could affect care quality. Because the study is a snapshot in time, it shows an association and cannot prove that workload itself causes the differences in prescribing.
Mukhopadhyay A, Sang Y, Blecker S, Blum M, Carrero J, Chang A, et al.. (2026). Association Between Cardiologist Ambulatory Workload and Evidence-Based Therapy for Heart Failure.. Journal of the American Heart Association. https://doi.org/10.1161/JAHA.125.048608