 |
|
Outcome Following Acute Myocardial Infarction
Are Differences Among Physician Specialties the Result of Quality of Care or Case Mix?
Craig D. Frances, MD;
Alan S. Go, MD;
Kent W. Dauterman, MD;
Kamala Deosaransingh, MPH;
Dexter L. Jung, PhD;
Sharmeen Gettner, MS, PhD;
Jeff M. Newman, MD, MPH;
Barry M. Massie, MD;
Warren S. Browner, MD, MPH
Arch Intern Med. 1999;159:1429-1436.
Background Studies to determine whether care by cardiologists improves the survival of patients with acute myocardial infarction (MI) have produced conflicting results, and it is not known what accounts for differences in patient outcome by physician specialty.
Objectives To evaluate whether cardiologists provide more recommended therapies to elderly patients with acute MI and, if so, to determine whether variations in processes of care account for differences in patient outcome.
Design Retrospective cohort study using medical chart data and administrative data files.
Setting All nonfederal acute care hospitals in California.
Patients A cohort of 7663 Medicare beneficiaries 65 years and older directly admitted to the hospital with a confirmed acute MI from April 1994 to July 1995 with complete data regarding potential contraindications to recommended therapies.
Main Outcome Measures Percentage of "good" and "ideal" candidates for a given acute MI therapy who actually received that therapy, percentage who received exercise stress testing or coronary angiography, percentage who underwent revascularization, and 1-year mortality, stratified by specialty of the attending physician.
Results During hospitalization, good candidates for aspirin were more likely to receive aspirin if they were treated by cardiologists (87%) than by medical subspecialists (73%; P<.001), general internists (84%; P=.003), or family practitioners (81%; P<.001). Cardiologists were also more likely to treat good candidates with thrombolytic therapy (51%) than were medical subspecialists (29%; P<.001), general internists (40%; P<.001), or family practitioners (27%; P<.001). Patients of cardiologists were 2- to 4-fold more likely to undergo a revascularization procedure. Despite these differences in utilization, we found similar 30-day mortality rates across physician specialties. However, 1-year mortality rates were greater for patients treated by medical subspecialists (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.6-2.3), general internists (OR, 1.4; 95% CI, 1.3-1.6), and family practitioners (OR, 1.7; 95% CI, 1.4-1.9) than for those treated by cardiologists. Adjusting for differences in patient and hospital characteristics markedly reduced the ORs for those treated by medical subspecialists (OR, 1.2; 95% CI, 0.9-1.4), general internists (OR, 1.1; 95% CI, 1.0-1.3), and family practitioners (OR, 1.3; 95% CI, 1.1-1.6), whereas further adjustment for medication use and revascularization procedures had little effect.
Conclusions Differences in the use of recommended therapies by physician specialty are generally small and do not explain differences in patient outcome. In comparison, differences among patients treated by physicians of various specialties (case mix) have a large impact on patient outcome and may account for the residual survival advantage of patients treated by cardiologists. With the exception of the in-hospital use of aspirin, recommended MI therapies are markedly underused, regardless of the specialty of the physician.
From the Department of Medicine, University of California, San Francisco (Drs Frances, Go, Dauterman, Massie, and Browner); Veterans Affairs Medical Center (Drs Frances, Go, Dauterman, Massie, and Browner); and California Medical Research, Inc (Ms Deosaransingh and Drs Jung, Gettner, and Newman), San Francisco, Calif.
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati  Twitter
What's this?
RELATED ARTICLE
Archives of Internal Medicine Reader's Choice: Continuing Medical Education
Arch Intern Med. 1999;159(13):1503.
FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Myocardial infarction and quality of care
Chen and Normand
CMAJ 2008;179:875-876.
FULL TEXT
Influence of Inpatient Service Specialty on Care Processes and Outcomes for Patients With Non-ST-Segment Elevation Acute Coronary Syndromes
Roe et al.
Circulation 2007;116:1153-1161.
ABSTRACT
| FULL TEXT
Myocardial Infarction Mortality in Rural and Urban Hospitals: Rethinking Measures of Quality of Care
James et al.
Ann Fam Med 2007;5:105-111.
ABSTRACT
| FULL TEXT
A Comparison of Outcomes Resulting From Generalist vs Specialist Care for a Single Discrete Medical Condition: A Systematic Review and Methodologic Critique
Smetana et al.
Arch Intern Med 2007;167:10-20.
ABSTRACT
| FULL TEXT
Long-Term and Short-Term Changes in Antihypertensive Prescribing by Office-Based Physicians in the United States
Stafford et al.
Hypertension 2006;48:213-218.
ABSTRACT
| FULL TEXT
Impact of specialty of admitting physician and type of hospital on care and outcome for myocardial infarction in England and Wales during 2004-5: observational study
Birkhead et al.
BMJ 2006;332:1306-1311.
ABSTRACT
| FULL TEXT
A systematic review of studies comparing myocardial infarction mortality for generalists and specialists: lessons for research and health policy.
Hartz and James
J Am Board Fam Med 2006;19:291-302.
ABSTRACT
| FULL TEXT
Socioeconomic Status and Mortality after Acute Myocardial Infarction
Alter et al.
ANN INTERN MED 2006;144:82-93.
ABSTRACT
| FULL TEXT
Regionalization of Care for Acute Coronary Syndromes: More Evidence Is Needed
Rathore et al.
JAMA 2005;293:1383-1387.
FULL TEXT
An Australian comparison of specialist care of acute myocardial infarction
SCOTT et al.
Int J Qual Health Care 2003;15:155-161.
ABSTRACT
| FULL TEXT
Cardiology participation improves outcomes in patients with new-onset heart failure in the outpatient setting
Ansari et al.
J Am Coll Cardiol 2003;41:62-68.
ABSTRACT
| FULL TEXT
Specialty of Ambulatory Care Physicians and Mortality among Elderly Patients after Myocardial Infarction
Ayanian et al.
NEJM 2002;347:1678-1686.
ABSTRACT
| FULL TEXT
Profiling Care Provided by Different Groups of Physicians: Effects of Patient Case-Mix (Bias) and Physician-Level Clustering on Quality Assessment Results
Greenfield et al.
ANN INTERN MED 2002;136:111-121.
ABSTRACT
| FULL TEXT
Urban-Rural Differences in the Quality of Care for Medicare Patients With Acute Myocardial Infarction
Sheikh and Bullock
Arch Intern Med 2001;161:737-743.
ABSTRACT
| FULL TEXT
The Quest to Quantify Quality
Fihn
JAMA 2000;283:1740-1742.
FULL TEXT
|
