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John Z. Ayanian, MD, MPP; Edward Guadagnoli, PhD; Barbara J. McNeil, MD, PhD; Paul D. Cleary, PhD

Arch Intern Med. 1997;157(22):2570-2576.

Abstract
Background
Both cardiologists and generalist physicians care for patients with acute myocardial infarction, but little is known about their patients' characteristics, treatments, and outcomes.

Methods
We identified attending and consulting physicians, patient characteristics, drugs, procedures, and mortality from clinical and administrative records of 1620 Medicare beneficiaries aged 65 to 79 years who were treated for acute myocardial infarction at 285 hospitals in Texas during 1990.

Results
Patients treated by attending cardiologists were younger, had prior congestive heart failure less frequently, and were initially treated in hospitals offering coronary angioplasty or bypass surgery more often than patients treated by attending generalist physicians (for each, P<.004). Adjusting for patient and hospital characteristics, cardiologists were more likely than generalist physicians to prescribe thrombolytic therapy and aspirin (P<.05) but not β-adrenergic blocking agents (β-blockers). Cardiologists used coronary angiography and angioplasty more often (P<.003), but not echocardiography or exercise testing. Adjusted 1-year mortality did not differ significantly between patients of attending cardiologists and generalist physicians (odds ratio, 1.01; 95% confidence interval, 0.76-1.35) or between patients of generalist physicians with and without a consulting cardiologist (odds ratio, 0.83; 95% confidence interval, 0.60-1.16). However, patients initially admitted to hospitals offering coronary angioplasty and bypass surgery had lower adjusted 1-year mortality than patients admitted to other hospitals (odds ratio, 0.68; 95% confidence interval, 0.47-0.98).

Conclusions
Compared with generalist physicians, cardiologists used some, but not all, effective drugs more frequently, as well as coronary angiography and angioplasty. Although these differences were not associated with lower adjusted mortality among cardiologists' patients, cardiologists were more likely to treat patients in hospitals with better outcomes. Future studies should identify organizational factors that improve outcomes of myocardial infarction.

Arch Intern Med. 1997;157:2570-2576

Author Affiliations
From the Division of General Medicine, Section on Health Services and Policy Research, Departments of Medicine (Dr Ayanian) and Radiology (Dr McNeil), Brigham and Women's Hospital and Harvard Medical School, and the Department of Health Care Policy, Harvard Medical School (Drs Ayanian, Guadagnoli, McNeil, and Cleary), Boston, Mass.

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